Overview:
Under the Social Security Act, reimbursement for telehealth under Medicare has been subject to stringent restrictions.
Only patients in certain identified practice settings in rural,
physician-underserved areas were eligible. Care into the patient's home
was not covered. Only certain providers were eligible. With rare
exceptions, only real-time, audio-video communications were eligible.
And, only a rather modest number of CPT codes were eligible.
Most of these provisions are still good law. In 2015, however, the first
modification of these rules appeared, allowing reimbursement, still
subject to extensive restrictions, for chronic care management. Because a
co-pay had to be charged, patient consent was required, for services
that the patient had previously received at no charge. Plenty of other
limitations were imposed as well.
For the first time, however, distance care services provided by
staffers, as opposed to qualified HCPs, and delivered by email or phone,
for example, as opposed to by videoconferencing, could satisfy
Medicare's requirements for reimbursement. In 2018, CMS developed the
highly creative concept of communication technology-based services
(“CBTS”), distinguished from telemedicine on the theory that these are
not simply substitutes for in-person care, but are inherently electronic
in nature and thus outside the scope of the telemedicine reimbursement
rules of the Social Security Act.
Consent and co-pay provisions attend these services also, as well as
somewhat onerous “related visit rules” that to some degree limit the
value of this opportunity. Nevertheless, it is now possible to be
reimbursed for remote evaluation of patient-generated images and videos;
for so-called “virtual check-ins,” designed to determine whether an
in-person evaluation is necessary; and for interprofessional
consultations.
In addition, reimbursement for remote patient monitoring (“RPM”) is both
more generous and easier to obtain under CBTS reasoning than it had
been before this innovation. In particular, originating site and
geographic restrictions on RPM reimbursement are now things of the past.
The Bipartisan Budget Act of 2018 and the SUPPORT Act expanded
reimbursement opportunities as well.
Under the BBA, Medicare Advantage plans may offer “additional telehealth
benefits” as part of “basic benefits” not otherwise available in
Original Medicare under Part C, and may “treat them as basic benefits
for purposes of bid submission and payment by CMS.” Renal dialysis
facilities and a beneficiary's home may now serve as originating sites
for dialysis and monthly ESRD-related clinical assessments.
Coverage became available for acute stroke telehealth services in any
hospital, CAH, mobile stroke unit, or any other site determined
appropriate by the Secretary, in addition to the current telehealth
originating sites. Under the SUPPORT Act, CMS adjusted the telehealth
reimbursement rules for treating individuals anywhere in US with
substance use disorder or a co-occurring mental health disorder.
When in March of 2020 the President declared a state of emergency,
Congress enacted massive legislation to cope with the crisis. Many of
these enactments had substantial impact on telemedicine in general and
on reimbursement for it in particular. Among other significant changes,
massive infusions of funds permitted reimbursement for telehealth to
equal that for comparable in-person services.
Originating site rules were waived, as were rules distinguishing new
from established patients. The number of covered CPT codes increase
substantially. For the first time, audio-only services became eligible
for reimbursement. FQHCs and RHCs could serve not only as originating
sites but, for the first time, as distant sites also.
The list of providers eligible for Medicare reimbursement was enlarged
while the supervision requirements were relaxed. A burning question
right now is which if any of these and other changes will remain in
place once the pandemic is finally under control.
Why you should Attend:
Patients and employers are demanding distance care because it is
convenient; it expands access to care, including specialty services
often hard to obtain in many areas; it can save costs; and it improves
patient satisfaction.
As a result of the need to expand access to care during the pandemic,
yet to simultaneously minimize the risk of contagion. the demand for
this form of care reached unprecedented levels in the spring of 2020.
Thanks to vaccines and public health measures, peak demand has passed,
but telehealth utilization has stabilized at levels 38X higher than
before the pandemic. 95% of employers are confident their organizations
will continue to sponsor health care benefits in the next five years.
40% of millennials say that a telemedicine option is “extremely or very
important” to them.
Similarly, consumer and provider attitudes toward telehealth have
improved since the pre-COVID-19 era. Investment in virtual care and
digital health more broadly has skyrocketed.
Knowing how to offer such care, and how to get paid for it, is no longer
merely desirable; it has become essential. Unfortunately, however,
reimbursement has long been a problem with this sort of care, especially
for Medicare beneficiaries. The rules are complex, and subject to
change. As a result of legislation and a variety of waivers,
reimbursement has improved under the pandemic but whether and to what
extent these changes will remain in place is unclear at present.
Those attending this webinar will learn about the rationale for
telemedicine, and the historical restrictions on payment for it. We will
then consider the rise of chronic care management and the erosion of
the historical barriers to payment a) for care at home and b) for the
services of clinical staff; CMS’s newer regulatory approaches to
reimbursement; and the several communication technology-based services
that allow reimbursement for store-and-forward telemedicine, brief
check-ins with patients, interprofessional consults, and expanded access
to remote patient monitoring.
We will also examine Congress’s recent pandemic-related legislative
decisions, as well as associated regulatory flexibilities, all designed
to expand coverage for telehealth, and consider what future
reimbursement rules might look like. If you ignore these changes, you
may be denying access to services for some patients, and you are leaving
money on the table at the same time.
Areas Covered in the Session:
- The rationale for telehealth
- The traditional payment restrictions
- The legal limits on CMS's ability to reimburse distance care services
- Chronic care management and the change it represents
- The evolution in CMS's thinking about distance care
- The rise of communication technology-based services
- Congress's growing enthusiasm for telehealth
- New opportunities for distance care for ESRD, stroke, and SUD
- The changes wrought by the pandemic
- What the future of telehealth reimbursement may look like
Who Will Benefit:
- Hospital revenue cycle managers
- Hospital CEOs
- CFOs
- Hospital counsel
- Billers and coders
- Telemedicine service providers
- Telemedicine platform companies’ executives and sales and revenues professionals
- Office managers for medical practices
- Lawyers advising health care organizations and professionals
- Managed care providers
- Employee benefits professionals