Under the Social Security Act, reimbursement for telehealth under Medicare has been subject to stringent restrictions.
Only patients in certain identified practice settings in rural, physician-underserved areas were eligible. Care into the patient's home was not covered.
Only certain providers were eligible. With rare exceptions (demonstration sites in Hawaii and Alaska), only real-time, audio-video communications were eligible. And, only a rather modest number of CPT codes were eligible. These provisions are still good law. In 2015, however, the first modification of these rules appeared, allowing reimbursement, still subject to extensive restrictions, for chronic care management. Because a co-pay had to be charged, patient consent was required, for services that the patient had previously received at no charge.
Plenty of other limitations were imposed as well. For example, the patient has to have access to care management services 24/7, a comprehensive care plan has to be developed, only 1 practitioner/month is eligible for reimbursement, and providers have to document that clinical staff spent 20 minutes of non-in-person time in a given month.
For the first time, however, distance care services provided by staffers, as opposed to qualified HCPs, and delivered by email or phone, for example, as opposed to by videoconferencing, could satisfy Medicare's requirements for reimbursement. In 2018, CMS developed the highly creative concept of communication technology-based services ("CBTS"), distinguished from telemedicine on the theory that these are not simply substitutes for in-person care, but are inherently electronic in nature and thus outside the scope of the telemedicine reimbursement rules of the Social Security Act.
Consent and co-pay provisions attend these services also, as well as somewhat onerous "related visit rules" that to some degree limit the value of this new opportunity. Nevertheless, it is now possible to be reimbursed for remote evaluation of patient images and videos; for so-called "virtual check-ins," designed to determine whether an in-person evaluation is necessary; and for interprofessional consultations. In addition, reimbursement for remote patient monitoring ("RPM") is both more generous and easier to obtain under CBTS reasoning than it had been before this innovation. In particular, originating site and geographic restrictions on RPM reimbursement are now things of the past. By no means are these the only changes of note.
The Bipartisan Budget Act of 2018 and the SUPPORT Act have also expanded reimbursement opportunities as well. Under the BBA, Medicare Advantage plans may offer "additional telehealth benefits" as part of "basic benefits" not otherwise available in Original Medicare under Part C, and may "treat them as basic benefits for purposes of bid submission and payment by CMS." Renal dialysis facilities and a beneficiary's home may now serve as originating sites for dialysis and monthly ESRD-related clinical assessments.
Coverage is now available for acute stroke telehealth services in any hospital, CAH, mobile stroke unit, or any other site determined appropriate by the Secretary, in addition to the current telehealth originating sites. Under the SUPPORT Act, CMS adjusted the telehealth reimbursement rules for treating individuals anywhere in US with substance use disorder or a co-occurring mental health disorder.
The Agriculture Improvement Act of 2018 provides funding for both telehealth grants and for broadband expansion. In short, the reimbursement landscape has changed substantially, and these developments augur well for potential growth in telemedicine and all the benefits it will bring to both patients and providers.
Patients and employers are demanding distance care because it is convenient; it expands access to care, including specialty services often hard to obtain in many areas; it can save costs; and it improves patient satisfaction. Some 75% of all US hospitals now offer some form of telehealth service. Growing numbers of physicians are doing so as well, especially in such specialties as radiology, psychiatry, cardiology, and emergency medicine.
Knowing how to offer such care, and how to get paid for it, is no longer merely desirable; it has become essential. Unfortunately, however, reimbursement has long been a problem with this sort of care, especially for Medicare beneficiaries. Those attending this webinar will learn about the rationale for telemedicine, and the historical restrictions on payment for it.
We will then consider the rise of chronic care management and the erosion of the historical barriers to payment a) for care at home and b) for the services of clinical staff; CMS's new regulatory approaches to reimbursement; and the several communication technology-based services that for the first time allow reimbursement for store-and-forward telemedicine, brief check-ins with patients, interprofessional consults, and expanded access to remote patient monitoring.
We will also examine Congress's recent legislative decisions to expand coverage for ESRD, stroke care, substance use disorder management, and HHS's ET3 pilot program, which provides equal financial incentives for ambulances to deliver patients to an ED, to urgent care, or to offer care in place via telemedicine.
These changes do not solve all telemedicine reimbursement problems, but they are significant changes, nonetheless. If you ignore these changes, you may be denying access to services for some patients, and you are leaving money on the table at the same time.