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Your Quick Guide for Telemedicine Reimbursements


How does telemedicine reimbursement work? If you’re a practice trying to add telemedicine options to your services, it’s important that you understand the reimbursement model. Prior to the spread of COVID-19, reimbursement for virtual visits could be difficult. The coverage varies among payers. CMS has expanded meaningful coverage through 2021. With the global success and popularity of telemedicine options for practices and patients, we expect this service to continue to evolve and thrive.

Telemedicine provides many benefits for the patient and the practice. For your practice, this added service means better, more efficient patient care, offering convenience, improving loyalty in your patient base, and boosting your practice profits. To fully achieve all of these goals, you need to understand telemedicine reimbursement rates.

How to Get Reimbursed for Telemedicine Services

Currently, states have different laws governing telehealth coverage. Many states have parity laws, which means that the state requires insurance companies to cover telehealth visits the same way that they would cover an in-person visit. In states without parity laws, the telemedicine reimbursement rates will depend on the insurance company. For patients on Medicare or Medicaid, the reimbursement rules are swiftly changing. There have been changes to coverage for Medicare to address uses through the pandemic. Whether this coverage stays in place, expands, or diminishes will depend on the laws and amendments passed later this year, if any.

For your practice, this means that it’s absolutely integral to stay up to date with recent changes in state and federal laws that govern telemedicine coverage. You’ll also need to understand the different rules set about by insurance carriers. Remember, too, that many insurance carriers are seeing a benefit from offering telemedicine coverage for their customers. But each insurance company handles these services differently.

During the crisis period, some commercial payers are using normal E&M codes in cases where all parties cannot obtain audiovisual service. You need to verify this coverage with each specific payer

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Telemedicine Reimbursement by Private Payers

Private payers have been making their own rules about what to cover in states that don’t have laws regulating telehealth coverage. As of this writing, only seven states remain without parity laws in place for private payers. A lot of the larger insurance companies have added telemedicine coverage to their member benefits. During the pandemic, a number of insurers were making telehealth a free service for patients for a limited time. Current updates from CMS show that the emergency telehealth features will be extended through 2021.

The Center for Connected Health Policy has a good resource to see the different coverage available through private and government payers.

For practices, it’s important to verify the type of coverage the patient has in advance. Once you determine what their insurance covers, you can determine if the type of telehealth visit they require is covered under their policy. Patients can pay out of pocket, but it’s ideal for them if the visit is partially or completely covered.

There are some issues that you need to be aware of with private payers. Because they are not mandated to offer coverage in every state, some policies will not include telemedicine. Some payers will only include that service in certain types of plans. Verify coverage prior to service. You should also verify whether the reimbursement rate is the same for telehealth and in-person visits and whether there are any modifiers to the CPT or HCPCS codes. There may be payer specifics on copays, which should be verified, as well.

For patients who do not have telemedicine coverage, there is still the option for them to self-pay. There are many patients who will opt to do this because the service is convenient, meets their needs, and allows them better access to well care. If you have patients whose plans do not cover the service, let them know in advance and offer options for both care that is covered and telehealth.

Medicare Telehealth Reimbursement

The telemedicine reimbursement waiver for Medicare and Medicaid has been extended through 2021. This waiver expanded telehealth visits for patients, particularly those in a high-risk group, and extends through the public health emergency (PHE). Whether lawmakers will permanently add this coverage to Medicare and Medicaid services remains to be seen. We’ll know more about the permanent status of coverage in the coming months.

Here are some things for practices to keep in mind when billing Medicare/Medicaid for telehealth services:

  • You can bill the same rate for telehealth as you do for an in-person visit.
  • Medicare waives patient payment, which means that you will only be paid 80% of the allowable services that Medicare covers.
  • During PHE, cybersecurity regulations have been lifted to allow for wider use of platforms, such as Facetime and Zoom. (However, it’s to the practice and patient’s benefit to use the best security possible to protect data and prevent breaches).
  • CMS does require real-time audio and video for telehealth that falls under E/M visits.
  • You can provide services to a distant patient, providing they are in a Health Professional Shortage Area (HPSA).
  • Telehealth visits can be billed using POS codes that correlate to the codes that would have been used in an in-person visit.

Tips for Telemedicine Reimbursement

Some ideas to help your practice ensure telemedicine reimbursement:

  • Maintain updated information about different insurance policies and Medicare updates to verify quickly which ones offer coverage for telehealth.
  • Some payers update frequently. We expect plan coverage to continue to change rapidly and this is something your staff needs to be aware of.
  • Make sure that you understand the types of telehealth services and how they are properly coded.
  • Make sure that you include modifiers if the plan calls for them.
  • Verify whether insurance carriers allow you to bill telehealth visits at the same rate as in-person visits (many do).
  • Verify whether the patient is required to make a co-payment. Many plans have made telehealth free for the patient, which means that your practice will only receive money from the payer, minus the patient’s usual responsibility.

Telemedicine Reimbursement Rates, Billing, & CPT State Codes

We expect the telemedicine reimbursement rates, billing process, and CPT state codes to change. PHE has been extended through 2021, but there’s no doubt that insurers and patients have seen a dramatic benefit in the addition of telehealth services. We do expect that lawmakers and insurance carriers will continue to push for expanded coverage of these services.

The coding and billing requirements need to be met efficiently. In a changing environment with fluctuating rules, that can pose a problem.

At Bizmatics, we take care of the research and verification for you, to keep your billing and coding requirements up to date for streamlined revenue cycle management. Our Revenue Cycle Management team has a list of each payer with their coding requirements. We can also calculate reimbursements by the payer.

Contact us today if you’d like more information on Telemedicine Reimbursements for your practice.