Telemedicine: Reimbursement in fee-for-service, quality models

Younger generations of patients will demand immediate answers to their health-related questions via electronic information and telemedicine. We need to bring health care into the 21^st century. But how?

The provision of health care via technology and without direct eye-to-eye and skin-to-skin contact is an area of growing interest in the U.S. It is also an area of great concern. One of the key conundrums surrounding telemedicine is the when, how, and what to pay for the service.

The current health care system is in a state of change from a fee-for-service model to a quality-based grouped payment model. Telemedicine is viewed differently within the two types of systems. As with other services, working in one system with an eye toward the future raises some interesting questions.

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There are several drivers that appear to be influencing the growing interest in telemedicine, including the change in technology, growing patient need/demand, geographic challenges (urban vs. rural), and a projected shortage of physicians in many market segments.

Tempering the enthusiastic adoption of telemedicine are concerns for safety, abuse of the technology by those who are unqualified, legal implications, and clinical efficacy. These aspects of telemedicine are under study by many different groups.

As the market continues to speculate the “how” of telemedicine, there is little question that it will be a part of the health care delivery and payment system. Therefore, we dedicate this article more to the current possibilities of payment and the motivations of the players that will likely influence telehealth’s adoption.

Next: Payment in risk management model

Payment in risk management model

Payment under a risk management system or alternative payment model is based on an overall cost borne by the group or institution receiving the contract. A focus on overall costs borne by the caregiving group will have to include at least some focus on outcomes under the majority of payment systems that have appeared under this model.

In these models, if telemedicine proves to be cheaper to provide and can demonstrate at least clinical equivalence, it is hard to envision that groups will not adopt telemedicine to the greatest extent allowed. Groups are already using telephone triage and follow-up to ensure compliance with prescribed treatment.

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These groups will be forced to some degree to prove the efficacy of the services provided. Collecting data on what works and how much can be provided in an effort to grow the services provided with lower expenses will be important for marketing, patient buy-in, and safety measures. It is reasonable to assume that these groups will begin to push for medicolegal support as they develop the data.

We fully expect these groups to present the data and lead efforts to address the scope and reach of telemedicine services. These efforts, when successful, will have to be balanced with some value determination beyond that of clinical value to that of market value and in the end somehow tied to revenue indirectly. The combination of the value proposition and quality/efficacy will require that organizations in these models will need to collaborate to some degree with the forces of the market more focused on pricing the services.

Reimbursement in fee for service

Balancing the desire to provide the speed and access to health care afforded by telemedicine with a desire not to compete with current revenue-generating in-person encounters, the fee-for-service market faces a number of issues. Many payers and providers are exploring models that will generate revenue but require specific technologies or pathways that allow for control of costs.

Medicare began paying for some telemedicine services in 1999 and has expanded coverage and reduced restrictions each year. For 2017, Medicare covers a limited number of HCPCS and CPT codes for services provided using interactive video and audio services (Alaska and Hawaii beneficiaries can be covered if non-interactive technology is not used) as long as the patient is in an approved facility during the provision of service.

Modifer –GT is appended to the service reported to indicate the use of telemedicine technology. A list of the 89 covered services and specific requirements was included in the final rule for payment for Medicare in 2017. Additionally, there are limited markets in which telemedicine is covered.

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Private payers are also studying payment for telemedicine services. Of course, private payers have the ability to restrict coverage under benefit plans and provisions determining what specifically is required to meet the definition of telemedicine (typically interactive audio and video). Many of the larger payers have policies for telemedicine that are posted on websites or that can be checked prior to provision of service through typical prior authorization channels.

Telephone calls as a part of an office visit or follow-up of an office visit often do not qualify for payment under current telemedicine coverage rules. Currently, services such as pre-visit history and demographics discussion, follow-up for test results, and prescription refills fall into the “bundled” category of services and are therefore not currently paid separately.

Next: Current CPT codes

Current CPT codes

The current CPT codes that follow were introduced in the 2008 CPT code list and are the only CPT codes currently available for reporting telephone services.

99441: Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E&M service provided within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

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99442: Telephone evaluation and management service by a physician or other qualified health care professional who may report E&M services provided to an established patient, parent, or guardian not originating from a related E&M service provided within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.

99443: Telephone E&M service by a physician or other qualified health care professional who may report E&M services provided to an established patient, parent, or guardian not originating from a related E&M service provided within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion.

These descriptions are restrictive. Note the codes are for established patients and must be unrelated to E&M services provided within 7 days of an office visit and more than 24 hours prior to a new E&M visit.

These codes represent an option for established patient care; however, they are not covered by Medicare, and coverage by other payers is limited. As a non-covered service, the codes can be billed directly to the patient as a cash pay service under both Medicare and many private-sector plans. Many practices are beginning to offer the option of a telephone visit on a cash basis in lieu of an office visit. With high deductibles and high co-pays for specialists common in today’s health care market, proper positioning of these types of services as a cost and time saver has made this a marginally profitable service in some practices.

One final CPT code that is available is: 99444 (Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E&M service provided within the previous 7 days, using the Internet or similar electronic communications network).

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Although this code does not carry the established patient restriction, it does carry a technology description that would block this service from being reported without some technology more advanced than the phone.

All of the codes listed above, as well as the introductory instructions to these codes, emphasize the American Medical Association consideration of patient-physician relationship and the payer concerns for abuse of telephone-based care.

Next: What can you do now?

What’s next

Currently, there are 29 states with telemedicine parity laws and another eight states that are considering such legislation. For those states with parity laws, private payers are required to cover telemedicine services at rates that are equal to those paid as if the service were provided in person. The health care market in general has several pressure points that have many pushing for expanded telemedicine options, including the use of telephone-only care support.

It is apparent that telemedicine will be discussed in detail and the technology will continue to be used in many systems. Expanding coverage for interactive telemedicine over the past several years would indicate that the future for interactive video and audio medical services is bright indeed.

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Telephone-only services are much more in doubt. While demand for these services is growing, (a recent Medscape survey indicated a majority of patients would consider changing primary care providers if telemedicine was not offered by their existing provider) coverage for these services continues to be very limited.

What can you do now?

With a lack of accurate codes and coverage for telephone-only services, practices will have to consider both the cost and opportunities outside of traditional insurance coverage.

Due to a decision not to cover telephone-only services, most plans will allow a physician to charge a patient directly. If a practice markets these services well, they can provide a source of revenue. If the practice chooses not to charge for these services, but instead views the service as a cost center, it may still be an advantage to the practice. The analysis of cost versus revenue versus benefit is a worthwhile exercise for any practice.

Cost for this service should take into account both the cost of the personnel in time required to provide the service and the savings, if any, the phone services defray during an onsite visit. Some have calculated that the time/money spent to provide all or part of a service via telephone is obviously offset by the time saving and service bump that patients experience in the office.

From a benefit and marketing perspective, in a world driven increasingly by patient and general market review, the marketing value of the telephone service is already bearing fruit. This market value is quickly becoming one of the key value metrics included in payer/provider ratings.

In short, although telephone services are not an obvious source of new revenue, the use of the telephone services in health care do add value to medical practices.

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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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