Medicare Opens Up Virtual Health, Telehealth Reimbursement

• November 15, 2018
• Jennifer Boese

You wouldn’t believe it, but I recently had an episode of pink eye. Geez. Isn’t that only for kids? I certainly didn’t want to trek over to my primary care doctor’s office for something this simple. Instead, I used a virtual visit. It was a Saturday, too. I was able to talk personally with a nurse practitioner, have her look at my eyes (yup, pink eye), and send a prescription to the pharmacy within a few minutes. Quick and easy and convenient. Exactly what telehealth or virtual heath should be available for, right? I’m glad to see that the federal government – from Congress to the Department of Health & Human Services (HHS) – seems to agree that this modality is important for Medicare as well.

Over the past few years HHS has authorized various new opportunities for Medicare virtual/telehealth reimbursement associated with chronic care management, transitional care management and remote patient monitoring. In the last few months alone, there has been additional movement forward in Medicare reimbursement for telehealth and virtual health. Is there a difference between the two, you ask? Well yes, in Medicare, there is a distinction.

Under Medicare, “telehealth” relates to a long-standing statutory and regulatory construct tying Medicare reimbursement to specific services in certain locations by certain providers via certain modalities. If you fall outside of those prescriptive policies, it is, generally, not reimbursable under Medicare. As you can see from my virtual primary care visit, in the age of technology advancements, access issues, convenience and value-based, coordinated care, these “telehealth” policies are antiquated. However, the good news is that the Centers for Medicare and Medicaid Services (CMS) and Congress continue to recognize the role telehealth and virtual health will play in the future, and are working to adapt their policies for Medicare (and Medicaid).

Let’s take a look at progress from the last few months alone.
2019 Final Physician Fee Schedule Rule (PFS)

CMS released the final PFS on November 1. It includes multiple new Medicare policies for virtual health care, meaning these are not constrained by Medicare’s prescriptive “telehealth” regulations.

• Payment for a virtual check-in (brief, non-face-to-face appointments via communication technology for established patients) → not “telehealth”
• Payment for evaluation of patient-submitted video/images → not “telehealth”
• The above are also reimbursable at federally qualified health care centers and rural health clinics
• Separate payment for six codes for interprofessional consultations → not “telehealth”

CMS also added multiple Medicare policies under its telehealth regulations.

• Two add-on codes for prolonged preventive services → yes, “telehealth.” This means these are still confined to Medicare’s more restrictive telehealth regulations
• Several provisions of the Bipartisan Budget Act of 2018 (BBA 2018) implementing ESRD and stroke care expansions → yes, telehealth, but Congress is loosening up some of these restrictions for specific use cases (like treating ESRD or stroke)
• Substance Use Disorders (SUDs) or with co-occurring mental illness → yes, telehealth. Part of the SUPPORT Act signed into law in October to address the opioid epidemic, but again, Congress is loosening up restrictions for providing these services. [Medicaid guidance on SUDs is due to states within a year.]

2019 Proposed Medicare Advantage Rule

Also under the BBA 2018, Congress authorized Medicare Advantage plans in the future to incorporate telehealth as a base benefit beyond what is currently reimbursable under Medicare. On Oct. 26, CMS released a proposed rule on how to implement this policy.

BBA 2018 requires that the telehealth benefits are based on an applicable year and are clinically appropriate to furnish through electronic information and telecommunications technology. The good news is that CMS proposes to broadly interpret this statutory language.

For example, CMS proposes that “clinically appropriate” will not be determined by CMS, but by Medicare Advantage plans. In addition, the agency would place limited parameters around technology, indicating asynchronous or other forms of communications are appropriate, and that flexibility is needed as technology advancements continue. What a great regulatory mindset! While the policies are still only in proposed form, to me they reflect a recognition by CMS of the utility (and opportunity) this modality presents for the future.

I expect to see more and more attention to telehealth and virtual health by Congress and CMS in the future. Commercial plans and Medicaid programs across the country should make sure they allow for its broad usage as well, and providers should strategically evaluate how virtual health and telehealth fit into their future.

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