Guide: Telemedicine benefits held back by lack of reimbursements
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The Centers for Medicare and Medicaid Services and some commercial insurers are beginning to consider telemedicine reimbursement with new "S" telemedicine codes. Providers can help themselves by using the codes now, lobbying for their acceptance and keeping close watch on how they're affected by the ICD-10 transition taking place in 2014, said a coding expert offering advice to health information management leaders.
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Despite telemedicine's potential benefits -- such as increasing physician capacity, lowering costs and streamlining care coordination for a cash-strapped U.S. healthcare system -- telemedicine reimbursement lags behind traditional face-to-face care, said Caleb DesRosiers, attorney in Foley Hoag's Health Care Practice and Government Strategies groups.
The standard of care now is that a primary care doctor can't be with a patient 24/7.
attorney, Foley Hoag
Technical issues holding back telemedicine implementations run the gamut from EHR systems that are not interoperable with telemedicine technologies, to designs that are incompatible with physician workflows. Deep in the health IT weeds, but perhaps an even bigger barrier, is the lack of back-office billing, coding and reimbursement for the telehealth care providers perform.
When seeking compensation for telemedicine services, providers generally have three options: Medicare, Medicaid and commercial insurance companies. Yet at this point, none of them have a uniform list of accepted codes or reimbursement rates. This inconsistency comes in part from a toxic political climate -- wherein some lawmakers consider telemedicine extraneous to care and reject plans to expand funding for it -- and in part from insurance companies who are meticulous about setting rates for services.
DesRosiers, who has worked under both private payers and the Centers for Medicare and Medicaid Services (CMS), said there's "chaos" among coders in different health systems and "resistance" to telemedicine reimbursement among different payers. He advised providers to not only use what codes they can now, but to get proactive and nudge legislation toward fairer coding and reimbursement practices for the future.
Looking at the industry as a whole, he suggested hospital information managers -- and the executives and chief information officers working with them -- implement billing systems and keep a few things in mind when fine-tuning telemedicine claims:
- Realize it's likely to have a strong set of codes with no reimbursements attached to them. Though the CMS just rolled out newly approved reimbursement codes for 2013 -- adding eight new codes applicable to telehealth -- providers should prepare billing staff to lobby for reimbursement of claims using those new codes once they're submitted and rejected. On the plus side, DesRosiers said, "the dollars are there" at the CMS, they just need to be allocated to telemedicine.
- When it comes to reimbursements, your best bet is commercial payers or Medicaid. Medicare has very limited billing codes for telehealth, DesRosiers said, but if a provider submits a telemedicine code to the CMS for Medicaid, they will almost always approve it (usually after 90 days). The other piece, he said, is that because Medicaid is a joint federal and state program, it yields a clear picture of how many states are using telehealth services, and that number is on the rise. What's more, the federal government can sometimes add money to state Medicaid coffers for telemedicine reimbursement.
- Though there's no be-all-end-all telemedicine code, try the S9110. Created by the CMS in 2013, the S9110 code isn't recognized on Medicare claims, but can be submitted to commercial payers and Medicaid if a provider lobbies for its use. It covers telemonitoring of patients in their homes, including all necessary equipment, maintenance, patient education and support. The code effectively replaces S9109, which previously had narrowly defined telehealth and limited it to one disease state.
- When lobbying policymakers, emphasize telemedicine's limited user population. DesRosiers said legislators are always reluctant to add services that cost money -- they're looking for savings. Because cost-scoring tools only measure hard, up-front costs and cannot prove secondary savings that telemedicine technology brings, such as docs using their time more efficiently, providers should emphasize the narrow scope of the services to lawmakers. "It's not going to be everybody and their uncle having telemedicine," he said, but just a few, targeted patients.
- Following ICD-10 conversion in 2014, telemedicine codes will likely be refined, not replaced. ICD-10's initial effect on telemedicine codes will encourage expanding access to providers who currently have limited access to using them on claims, such as home health providers, DesRosiers said. From there, they'll be refined, not reinvented, to further accommodate new users. Keep an eye on the advantages of ICD-10 as it rolls out.
- Many accountable care organizations (ACOs) are self-funding telehealth services. For ACOs, DesRosiers said, coding telehealth is less about reaping reimbursements and more about accurately tracking telemedicine services in electronic health records. He said ACOs are aligning with care management organizations and home health agencies to offer self-funded remote patient monitoring systems because "they believe in the return on investment."
- Understand that at the end of the day, the payer determines the rate. It's up to providers to call up payers and make sure they're aware of the outlying implementation and post go-live costs associated with telemedicine; things like training, consulting, technology and support, DesRosiers said. "The rates can't be anemic. It's a matter of them understanding these new codes, but more importantly, digging in further and asking, 'Is there an economic value to these codes?'" he said, adding that providers should use case studies as evidence for telemedicine's return on investment.
- Hospitals that own home health agencies should lead the effort. Bigger hospitals can make sure everyone in their network gets adequately reimbursed, DesRosiers said, by teaming with associations like the American Telemedicine Association and the American Association of Family Physicians to spearhead lobbying. DesRosiers said providers can access toolkits online with sample letters that model policies from other payer plans. And if a payer does cover telehealth benefits, he said, work to expand them.
- It's only up from here. DesRosiers pointed out that it took 40 years to add prescription drug coverage to Medicare, so it may be a "couple years" before they move to include telehealth. That being said, as standards shift toward coordinated care and technology gets more refined, it adds value to patient care, and telemedicine is ripe for those initiatives. "The standard of care now is that a primary care doctor can't be with a patient 24/7," he said. "These codes are not the panacea, but a one-size-fits-all policy is outdated."