Basics of Telemedicine Reimbursement
Basics of Telemedicine Reimbursement
Medical billing for telemedicine services can be tricky. As a relatively new care method for the wider patient population, the guidelines for billing telemedicine are still forming. In fact, the rules for billing telemedicine can often vary from payer to payer. In this article, we have shared the basics of telemedicine reimbursement. Telemedicine reimbursement can vary a lot depending on your state, practice, services, and the third-party payer.
Major commercial payers like Blue Cross Blue Shield, Aetna, Humana, Cigna, United Healthcare covers telemedicine. However, the important thing to note is that these payers will sometimes put telemedicine services on their policy exclusions list. So while Blue Cross Blue Shield may say they cover telemedicine, a gold PPO in North Carolina policy may cover it in full, while a cheaper bronze policy in NC may list telemedicine under its exclusions.
Basics of Telemedicine Reimbursement
Here are some basic tips and guidelines to help you navigate reimbursement for your practice.
Determine the Type of Telemedicine
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. Most payers advise providers billing telemedicine to use the appropriate evaluative and management CPT code (99201 – 05, 99211-15) along with a GT modifier.
Medicare covers a long list of eligible CPT codes and some private payers may prefer that you use the telemedicine specific code 99444. It varies based on the payer and the state you live in. In all except two states, Medicare reimburses for live video telemedicine and not store-and-forward (also called asynchronous) solutions.
Verify Patient Insurance Coverage
The best way to ensure you can bill and get paid for telemedicine is to call and verify coverage with the patient’s insurance before their first telemedicine visit. While this takes a little work, you only have to do it once for that policy.
When you call the payer, make sure you have a telemedicine insurance verification form handy to document the representative’s answers. If you have everything documented on that form with the call reference number, you can use that later to fight a denied claim.
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.
Navigating Medicare
The patient must be in an HPSA (Health Professional Shortage Area). In order to be eligible for Medicare reimbursement, the patient (Medicare beneficiary) needs to be receiving virtual care at one of the clinical settings which must be located within a Health Professional Shortage Area (HPSA).
Medicare has a specific list of CPT and HCPCS codes that are covered under telemedicine services. 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.
Medicare will also pay the originating site a facility fee, as reimbursement for hosting the telemedicine visit. A new place of service (POS) code 02 has been created for telehealth. 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.
Dealing with Private Payers
As mentioned earlier, major commercial payers like Blue Cross Blue Shield, Aetna, Humana, Cigna, United Healthcare covers 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.
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 telemedicine CPT codes on hand. 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?
Bill a Facility Fee
Most providers billing telemedicine don’t need to know about facility fees. But if you are part of a telemedicine program that bills through Medicare (and sometimes Medicaid), you should. A facility fee is essentially an amount paid to the local healthcare facility that hosts the patient during a telemedicine visit.
In the current Medicare telemedicine model, for instance, a patient has to come into an eligible originating site to start the telemedicine visit with a healthcare provider at another, distant site. That originating site can then charge a facility fee to cover the costs of hosting the visit. To charge that facility fee, you can bill HCPCS code Q3014. Look up the HCPCS code for full details about the facility fee.
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. 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.
Ready to get started billing telemedicine? Hopefully, this gave you the basics you need to get started. Feel free to call E2E Medical Billing Services at 888-552-1290 or write to us at info@e2eMedicalBilling.com