What will telehealth reimbursement look like post public health emergency?

The COVID-19 Public Health Emergency (PHE) ended on May 11, 2023. The PHE allowed provision of telehealth and audio-based services to Medicare patients regardless of location. Overnight, remote provision of health care moved from a potential solution for a shortage of physicians to the only way patients could receive care. Health care professionals in the United States quickly adapted and telehealth became the norm. The success and convenience of telehealth for Medicare during the PHE has driven support for long-term changes in the Medicare program; unfortunately, the US Congress and the federal government have not acted to make telehealth and telephone-based services permanent.

Jonathan Rubenstein, MD

We have received questions about telehealth and telephone-based service coverage for Medicare. The information posted on Medicare and carrier websites about the end of the PHE have lagged changes enacted by Congress. Further, we have only limited published information regarding Medicare interpretation of some current legislation. In this article, we will emphasize what we know and provide suggestions regarding telehealth post PHE.

Mark Painter

First, we need to understand the legislation. Medicare rules prior to the pandemic placed restrictions on coverage for telehealth in general and prohibited evaluation/management services via telephone (audio only). Before the pandemic, Medicare added some technology-based service coverage for patient interactions (portal services) and remote patient and therapeutic monitoring, as well as for telehealth services for patients in health professional shortage areas in limited supervised settings. Payment for these services, as well as the restrictions required by Medicare rules, limited their use. The PHE allowed Medicare to remove many of these payment restrictions and to set payment rates to equal in-person services, allowing physician groups to provide telehealth and audio-only services to Medicare patients regardless of patient location.

As the pandemic rules started to phase out in many states and numbers of infections and deaths dropped, it became apparent that the PHE would be allowed to expire, barring a new variant. Congress began to anticipate the end of the PHE but was not prepared to permanently adopt the pandemic rules for telehealth and audio services. However, Congress did try to ease the transition to post-PHE rules for these services, first in March 2022 and again in December 2022. The Consolidated Appropriations Act (CAA) of 2022 (signed into law in March 2022) included a provision extending Medicare coverage for telehealth services under PHE rules for 151 days after the end of the PHE with few exceptions. The Consolidated Appropriations Act of 2023 (passed in December 2022) extended the coverage directive through the end of 2024.

Medicare, in the final rule for the Physicians Fee Schedule, adopted the CAA 2022 rules for the calendar year 2023, apparently anticipating that the PHE would be allowed to expire. Therefore, we know Medicare will continue to pay at PHE rates and under PHE rules for telehealth and audio-only services through the end of 2023. In short, you may continue to use telehealth and audio-only services and expect the same reimbursement from Medicare as if the PHE were still in place.

We will have to review the final rule for calendar year 2024 to see whether Medicare, although required to cover telehealth and audio-only services through the end of calendar year 2024, will allow payment rates to remain at current PHE levels or will adjust them relative to the amount of the Practice Expense portion of the Medicare fee.

The end of the PHE requires some changes. There are 2 significant issues to which practices will need to adapt as of May 11, 2023. First, Health Insurance Portability and Accountability Act (HIPAA) exemptions have expired. Practices will now be required to provide HIPAA-compliant software and hardware for all telehealth and audio-only services. Second, the prescription of controlled substances allowed without in-person visits during the PHE will now need to be initiated during an in-person visit. Renewal of these substances for patients is allowed under certain circumstances, but you will need to comply with these restrictions at this point.

We are anticipating that telehealth will eventually be addressed with permanent legislation as there are multiple bills with bipartisan support driven by broad patient and physician satisfaction with the technology. Audio-only services do not currently have the same broad support, and the future of these services is in question.

Based on what we do know, we are recommending to practices that they permanently adopt telehealth. Here are some suggestions:

• Identify what visits are appropriate for telehealth. Truly diagnostic and new patient visits that would require an in-person physical examination or point-of-care testing or other information that cannot be obtained via telehealth would best be excluded from general planning and should be reserved for emergent situations only. Time-based (discussion) visits are ideally suited for telehealth. Patients are using telehealth with most specialties. As familiarity with telehealth grows, so will demand. Many practices have told us their patient populations cannot use telehealth for various reasons. Although this may have been true for a sizable percentage of the population at the beginning of the PHE, many have been forced to adapt and use telehealth, meaning the number of patients who can use telehealth has significantly increased. Telehealth may not be a solution for all patients, but as use grows, ignoring telehealth is a mistake. Focus the program on those you can help and leverage it.
• Telehealth visits save patients and physicians time and money. Work to make the experience for patient and physician efficient and effective. Reserve blocks of time for telehealth so you can stay on schedule with patients. Communicate your expectations to patients and ask them to avoid being in the car or in a place they cannot interact appropriately. Add support staff to “room” your telehealth visits, use appropriate talent and employees to deal with technical issues, and let your physicians and advanced practice providers focus on clinical support.
• Adopt, use, and train on HIPAA-compliant systems.
• Develop, deploy, and require patients to sign telehealth consent forms in person or via DocuSign-type technology. Train staff and enforce documentation requirements that include patient consent for visits and notation of appropriate video and audio connections in addition to standard clinical and medical necessity language.

Telehealth is here to stay. Lean into the technology as the new line of business that it is.