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Telehealth Services: Understanding Issues with Reimbursement

May 26, 2015

Telehealth_an_reimursementThe telehealth industry is continuing to grow at a surprising rate, leading to better patient care and even cost savings.  However, there is one issue that rises above all others in the in this industry; the issuing of payment.  Here’s a closer look at the latest reimbursement landscape found in this sector. 

Medicare Coverage: The Process of Reimbursement

When it comes to providing a reimbursement, no payer can be categorized the same as Medicare.  And with fewer than 20 sections of telehealth services being covered by Medicare, it makes the reimbursement process all the more complicated.  In regards to being restrictive, Medicare is one of the most extreme insurance providers.  In order for a reimbursement to be made by Medicare, a patient must meet the following criteria:

  • Seen at an authorized site; skilled nursing facilities, doctor offices, public hospitals, some private hospitals
  • Seen by an approved provider; nurse practitioner, doctor with medical degree, clinical psychologist, etc.
  • The exact service must be included within the codes that are covered

To fully understand how the reimbursement process works, you need to understand what a HPSA and MSA are.  HSPA stands for Health Professional Shortage Area.  If a reimbursement is to be provided by Medicare, the services must be conducted in a facility that is located in a HPSA.  And this facility cannot be included within a Metropolitan Statistical Area (MSA).

In 2011, Medicare only spent $6 million on telehealth service reimbursements.  

It has been stated that it will take an act of Congress for the reimbursement coverage to be expanded.  And with federal regulators in place, this makes it all the more difficult to get telehealth services approved.  As of right now, they are being approved are those that are provided to rural beneficiaries.

Medicaid Coverage: The Process of Reimbursement 

Medicaid reimbursement for telehealth services has been approved in about 40 states.  Each state’s exact reimbursement policy differs, with some providing coverage for real-time visits, while other provide coverage for off-site services, such as telehome care.  There are even some remote monitoring services covered.  And while the reimbursements for these types of services aren’t ideal, they are definitely far more expansive than those provided through Medicare.  

Private Payer: The Process of Reimbursement 

Although Medicare and Medicaid are causing some of the largest issues to arise in the reimbursement, private payer coverage is paving the way toward broader telehealth coverage.  The exact reimbursement policies of course vary from one private payer to the other.  It should be noted, though, that many states have jumped on the telehealth parity statutes bandwagon.  The included laws within these statutes mandate health insurers to provide reimbursement in the same way that they provide coverage for in-person services.  

Coverage of Telehealth Services: It’s a World of Opportunities

Even though there are many reimbursement issues arising within the telehealth sector, there are opportunities for coverage to expand, as well.  For starters, most likely it will soon be more broadly covered within government programs, such as the Veterans Administration (VA).  And being that increased attention is taking place in relation to telehealth services, health care reform initiatives are constantly monitoring the effectiveness of the services.  After a few years of collecting and analyzing data, it will be clearer to see that cost-savings are achieved through telehealth services.  And lastly, because there is an increased focus on ensuring re-admissions do not occur under Medicare coverage, this may force the insurer to direct its policyholders toward alternative forms of medical care, namely telehealth services.

M-Scribe, a leader in medical billing and coding, can help practices of all sizes save time and money – contact one of their professionals today to learn how we can help your practice in telehealth service, code-compliant, reduce denied claims and increase revenues.


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