Telemedicine Reimbursement Guide
Tips to help you navigate reimbursement.
How To Get Reimbursed for Telehealth
Getting reimbursed for telehealth services can be tricky. There’s no doubt about that. The reimbursement guidelines vary greatly based on the payer, and are still constantly changing as more of the healthcare industry jumps on the telemedicine bandwagon.
To help guide you through billing and reimbursement, our eVisit team has done some research to answer the common questions we hear from providers. How do you bill for telemedicine? What do you need to know about state telemedicine policy? How does reimbursement differ for Medicare or Medicaid vs. private payers?
The bottom line is telehealth reimbursement can vary a lot depending on your state, practice, services, and the third-party payer. Here are some basic tips and guidelines to help you navigate reimbursement for your practice.
Tips for Telemedicine Reimbursement
1) Determine the type of telehealth.
There’s a huge range of telehealth services available. Are you considering a live video solution? Software for remote patient monitoring? The type of telemedicine solution you’re using will affect how you bill and how you get reimbursed. For instance, in all except two states, Medicare reimburses for live video telemedicine and not store-and-forward (also called asynchronous) solutions.
2) Define your use case.
How will you be using telemedicine? Will you be using it to check-in with patients after hospital discharge? To treat patients with minor acute conditions like infections? To consult a specialist during a patient visit? Researching reimbursement will be easier if you have a specific use case in mind.
3) Navigating Medicare.
Here are a few things you need to know about Medicare and reimbursement for telemedicine services:
- Defining Originating and Distant Site. Defining the Originating and Distant Sites. Medicare reimburses for telehealth services offered by a healthcare provider at a Distant Site, to a Medicare beneficiary (the patient) at an Originating Site. The originating site must be in a HPSA (Health Professional Shortage Area). The types of originating sites authorized by law are:
- Physicians or practitioner offices
- Critical Access Hospitals (CAH)
- Rural Health Clinics
- Federally Qualified Health Centers
- Hospital-based or CAH-based Renal Dialysis Centers
- Skilled Nursing Facilities (SNF)
- Community Mental Health Centers (CMHC)
- Note: Independent Renal Dialysis Facilities are not eligible originating site
- The patient must be in a HPSA. In order to be eligible for Medicare reimbursement, the patient (Medicare beneficiary) needs to be receiving virtual care at one of the clinical settings mentioned above, that is also located within a Health Professional Shortage Area (HPSA). To see if the health facility is in a HPSA, type in their address to this CMS tool.
- Only certain CPT and HCPCS codes are eligible for telemedicine reimbursement. Medicare has a specific list of CPT and HCPCS codes that are covered under telemedicine services. You can use our printable list of the eligible CPT and HCPCS codes in our complete PDF Guide to Telemedicine Reimbursement as a quick cheatsheet. Since that list is subject to change each year, we also recommend you check the CMS website.
- Use the proper modifier. When billing for telemedicine visits, you need to use the 95 modifier code for commercial insurance plans, while the “GT” modifier must be included for Medicare and Medicaid plans.
- Billing a facility fee. Medicare will also pay the originating site a facility fee, as reimbursement for hosting the telemedicine visit. For details on the facility fee, look up the HCPCS code Q3014. A new place of service (POS) code 02 has been created for telehealth.
- Telemedicine reimbursement rates. Medicare reimburses telemedicine services at the same rate as the comparable in-person medical service, based on the current Medicare physician fee schedule. Plus, the facility serving as the originating site can charge an additional facility fee.
- Know where to find more information. Check out this helpful PDF and resource list from the Medicare Learning network, if you have additional questions.
4) Dealing with Private Payers
Each private payer does telemedicine reimbursement a little differently. The good news is, many of the large insurance companies are seeing the benefits of telemedicine and starting to provide broader coverage. Here are a few things you should know.
- 29 States and DC currently require private payers to reimburse telemedicine. The list of states below (as of 10/2015) have enacted telemedicine parity laws, which require private payers to reimburse providers the same amount for telemedicine services as the comparable in-person service. To check for updates on state legislation, visit the ATA State policy center and review their helpful state legislation matrix.
- The big insurance carriers (BCBS, Aetna, Cigna, United Healthcare) cover telemedicine. The largest commercial payers do cover telemedicine. However, whether they will reimburse for a telemedicine service is policy-dependent, meaning one patient might be covered under their BCBS policy and another may not if their policy excludes telemedicine.
- Call your payers and ask the right questions.The best way to find out telemedicine reimbursement policies from your private payers is to pick up the phone and call their eligibility and benefits department. Have a list of the relevant CPT codes on hand (see our Complete Telemedicine Reimbursement Guide for the list!). Here are a few questions to ask:
- Which CPT and HCPCS codes can be completed via telemedicine?
- Are there any restrictions on the location of the patient or provider?
- Do I need to use a modifier (GT)?
- Does the reimbursement rate match the in-person rate?
- Which providers are eligible (physician, NP, PA)?
- Are there any specific notes that need to be included in the visit documentation?
- Verify the patient’s insurance. Since telemedicine is policy-dependent, you’ll need to verify that the patient’s insurance does cover it. You can use our sample telemedicine insurance verification form to call up the patient’s insurance carrier and record whether or not they’re covered.
5) Getting Paid through Medicaid.
With the constantly shifting state telemedicine policy landscape, you’ll need to do a little research to figure out how Medicaid reimbursement will work for your practice.
- Lookup the Medicaid telemedicine reimbursement in your state. Here are 3 great websites to help you research policy for your state:
- Criterion to research. We have a printer-friendly worksheet in our complete telemedicine reimbursement guide, but here’s a quick list of the factors you should be looking for, that could affect your telemedicine reimbursement through Medicaid.
- Health Services covered
- Eligible providers (NPs, PAs)
- Is Cross-state licensing allowed?
- Is a Pre-existing relationship with patient required?
- Location restrictions on patient or provider
- Applicable CPT codes
- Type of fee reimbursed (transmission, facility, or both)
- Connect with your local telehealth resource center. The U.S. has 14 regional telehealth resource centers that are there to help you out. If you have questions about telemedicine reimbursement in your state, look up your local center and give them a call. Here’s the complete list of regional telehealth centers.
6) Train your billing staff.
- Compile your research and share with your billing staff, and any providers using telemedicine. Billing staff will need to know the applicable codes and rules for each payer.
7. Charge patients convenience fee.
- If all else fails, or you’d prefer not to spend the time researching reimbursement, you always have the option to charge the patient directly and forgo reimbursement from a third-party. This may not be ideal, but many patients seem not to mind paying a fee for the added convenience of a telemedicine service. Many of our clients at eVisit charge a convenience fee from $30 – 75 per visit. Just make sure that if you are an in-network provider for that patient’s insurance, you have them sign a waiver agreeing not to use insurance for telemedicine visits.