We often get questions about telemedicine reimbursement because, let’s face it, navigating that process can be tough. The guidelines vary depending on the payer and your state, and are even shifting as we speak as new telemedicine policy gets passed. If you’re a busy healthcare provider, you just need to know the requirements fast.
Last month, I did a post on the top 10 FAQs about how to get paid for telemedicine through Medicare. This month, we move on to another category of payer – the private, commercial payers. How do the big commercial payers like Blue Cross Blue Shield (BCBS) handle telemedicine? Do they cover it? What guidelines do they have for billing?
I’ll answer all these questions and more based on our team’s recent research. Here are the top 10 FAQs about telemedicine reimbursement and private payers.
1) What’s a telemedicine parity law and how does it affect private payers?
Telemedicine parity laws are state laws that require private payers to reimburse telemedicine services the same way they would for in-person medical services. That means, if your state has a telemedicine parity law in place, then your private payers have to reimburse you!
Of course, there’s always fine print, and certain restrictions payers can add on. You’ll still need to check with your payers for specific guidelines.
2) Which states have passed telemedicine parity laws?
Right now, 29 states plus DC have passed telemedicine parity laws. An additional 8 states have proposed telemedicine parity laws on the table. To track telemedicine parity in your state, bookmark this fantastic state policy matrix from the ATA. They update it on a regular basis.
3) Which private payers cover telemedicine?
If your state has a telemedicine parity law, any of the private payers in your state should cover telemedicine. Otherwise, we’ve done a lot of calling around to the large, commercial payers and found the Big Five – Aetna, BCBS, Humana, Signa, and United Healthcare all cover telemedicine.
However, there’s another factor here you need to know: telemedicine is policy-dependent. This means a patient with a BCBS gold plan in North Carolina could have telemedicine listed on their policy as a covered health service; a patient in the same state with a BCBS silver plan might not. So just knowing whether the private payer covers telemedicine is not always the whole answer.
4) Well, then how do I know if my patient is covered for telemedicine?
We recommend verifying their insurance before doing the first telemedicine visit. The easiest way to check telemedicine coverage is always just to call the payer and ask the right questions. Make sure when you call that you record everything with an insurance verification form. You can use our sample form here. Having that paper filled out and on file is your golden ticket to getting paid. If the payer said on the record that the patient was covered for telemedicine, they can’t go back on that.
5) What type of telemedicine is covered (i.e. live video, store-and-forward, remote patient monitoring)?
While some payers do cover store-and-forward and remote patient monitoring services, the gold standard is live video telemedicine. It’s the most widely covered form of telemedicine, and the one people are usually referring to when they talk about telemedicine.
6) What health services can I deliver via telemedicine under private payers?
You’ll need to check with your payers on this, but generally we’ve found that private payers will reimburse for the standard Evaluative & Management services (for example, established outpatient patient office visit, 5 minutes). Many also reimburse for a variety of mental health and chronic care services.
7) Do private payers have restrictions on location of the patient or provider (similar to Medicare?)
Some do follow the more restrictive Medicare model where a patient needs to come into a local health facility and do the telemedicine visit from there. But many private payers are catching onto the new idea of telemedicine as care delivered to the patient at their convenience (from home, work, or anywhere) and are lessening these restrictions.
8) How do I code a telemedicine visit?
Private payers vary on this one. Here’s an example telehealth coding grid for a BCBS North Carolina Policy. Generally, you should ask whether they’ll accept the CPT code 99444 (online medical evaluation) or 99499. If they don’t accept those codes, they’ll probably advise you to use one of the outpatient evaluative and management CPT codes (99201 – 5, and 99211 - 5) plus a “GT” modifier to show the visit was done virtually. Always verify the accepted billing codes for telemedicine before you do the visit.
9) What will my reimbursement rate for telemedicine be?
We’ve found that many private payers will reimburse at the same rate as a comparable in-person visit. So, if you’re billing a telemedicine visit with a 99213 code plus a GT modifier, you would get paid the standard rate for that CPT code according to your physician fee schedule with that payer.
10) What does the future of telemedicine reimbursement look like for private payers?
Many of the large private payers have recently begun or are finishing up large telemedicine pilot programs to analyze the benefits of telemedicine. As the results start to come in and show significant cost-savings and positive effects on care quality and patient outcomes, private payers will be highly motivated to expand their reimbursement policies for telemedicine. We’re betting on significant, widespread changes coming soon!
Whew! That was a lot of information to consume. While answers to reimbursement questions are rarely black-and-white, this summary should give you some helpful context of how to approach telemedicine reimbursement with private payers.