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: