Getting Reimbursed for Telehealth

In 2016, telehealth became the No. 1 regulatory concern for health boards across the nation.  Most of their attention was focused on practicing across state lines.  In other words, is the patient located in the state where the provider is licensed during the telehealth visit?  If not, that’s an issue.  While lawmakers and physicians are fighting it out, they are also demanding greater parity for telehealth visits compared to in-office visits.  To this, we are seeing great strides being made.

As researchers continue to uncover evidence that telehealth not only increases access to treatment and improves health outcomes, but also saves money, payers are responding more and more by increasing their types of coverage and reimbursement rates for telehealth visits.  For patients with private insurance, there are approximately 35 states and the District of Columbia (DC) that have parity laws mandating similar coverage be provided for telehealth visits as is provided for regular office visits.  However, Medicare and Medicaid run a little differently.

The Centers for Medicare and Medicaid Services (CMS) imposes geographical restrictions stating that Medicare beneficiaries are eligible for telehealth services only If the patient presents at an approved originating site located in a county outside of a Metropolitan Statistical Area (MSA) or in a rural Health Professional Shortage Area (HPSA) located in a rural census tract.  They’ve provided an eligibility analyzer tool to help you determine your patient is presenting at an eligible site: Eligibility Analyzer. This tool allows you to enter the address of the originating site to determine its eligibility. Additionally, they require the use of telehealth technology that includes both video and audio components.

Medicaid works differently and varies from state to state.  At this time, a couple of states still do not have a definition for telehealth and/or telemedicine.  Also, 48 states along with DC currently reimburse for live video while only 22 states reimburse for remote patient monitoring. Also, some states require a certain amount of distance.  For instance, Medicaid recipients located in New Hampshire must follow the geographical restrictions that Medicare beneficiaries do.  However, in South Dakota, the originating site simply cannot be in the same community as the distant site provider.  Also, 29 states require providers to get informed consent from the Medicaid recipient before a telehealth visit can be carried out.

As of March 2017, 35 jurisdictions have laws that govern private payer telehealth reimbursement policies. However, many of these laws do not require reimbursement to be equal to in-person visits when the same service is being delivered.  This is an ongoing issue that many states are diligently working to correct.  To see what the laws are in your specific state, the Center for Connected Health Policy has created an interactive map that covers all aspects of telehealth with regards to private payers and Medicaid.  You can access that map here:  Interactive State Telehealth Map.

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