SAN JOSE, Calif. -- A doctor, a lawyer and a medical coding expert walk in to a room. While that might sound like the beginning of a really bad joke, health care CIOs must hear the punch line: "And they share their best strategies for getting telemedicine reimbursement from both commercial and government payers."
Hospitals that are building telemedicine into their service lines are struggling to make sense of the labyrinthine system of legally coding and billing for them. Organizations that want bean counters to sign off on their clinicians' otherwise solid ideas for new telehealth services have to begin by having conversations with those payers and understanding the different policies.
That's what experts discussed in a session in at the American Telemedicine Association's 2012 annual meeting, when telemedicine services vendor C30 Medical Group CEO Herb Rogove took the stage along with his company's attorney Patrick Moore, who specializes in legal issues surrounding telemedicine claims and compliance. They were accompanied by Kory Stetina, coding expert and founder of Torch Health Solutions, a consultancy specializing in getting large health systems' telemedicine services paid.
They shared their experiences with the clinical and IT-minded attendees, and gave them ideas to take home and bring up in planning meetings -- presumably, with coding staff in attendance -- for telemedicine implementations. Currently, C30 and Torch's most commonly reimbursed services include critical care consultations, inpatient emergency department consultations and some follow-up visits/services surrounding those consults.
Kory Stetinafounder, Torch Health Solutions
"I think there are a lot of providers that avoid the practice of billing because we have a market that's underdeveloped, and we have guidelines that are constantly changing -- and I think that is to the detriment to the industry's advancement, not to mention the expansion of the reimbursement policies themselves," Stetina said in urging attendees to take on the payers and bill for telemedicine reimbursement.
While the speakers were careful not to offer advice on specific services -- lest they incur liabilities or misrepresent reimbursement customs in one U.S. region as a national trend -- they did offer plenty of general advice for organizations that want to bill for telemedicine services.
Among their tips:
- Create a coding crosswalk for the services you as a provider typically provide via telemedicine, starting with CPT codes in the left-hand column, with columns representing each payer you deal with, as well as additional codes a payer requests when claims wend their way through the claims-processing department. Since each payer may use slightly different codes to define a particular telemedicine service, this reference will save time on successive claims and also create a "history" document that helps establish precedents for future claims.
- Proactively furnish documentation about the care provided, which helps prove your telemedicine services are exactly the same as those provided in-person and therefore should be reimbursed the same.
- While the federal Centers for Medicare and Medicaid Services (CMS) typically lead reimbursement trends -- commercial payers follow their lead -- remember that the reverse is true in telemedicine. If CMS rejects a claim, that doesn't necessarily mean that commercial payers will, too. Stetina said that more than 130 private plans nationally reimburse for telemedicine services, and many states have laws either in effect or soon to go into effect that require coverage of telemedicine services.
- CMS introduced "G codes" a few years ago to begin ground work for reimbursing telemedicine services. They updated guidance on using "G codes" last year. Billing and coding departments who check the site regularly for more policy updates can take advantage of changes that further open reimbursement policies.
- Understand your liabilities. Billing CMS for telemedicine services is more of a legal risk depending on how densely populated your area is. That dictates what Office of Management and Budget statistical category you're in, such as "metropolitan statistical area" (MSA), "micropolitan," and so on -- and CMS telemedicine reimbursement policies vary from region to region depending on population density -- typically with more rural areas getting more favorable reimbursements. But it still can be done in the city, Moore said, as long as providers mitigate risks by following CMS rules and proactively repaying CMS when they demand it for perceived erroneous payments.
- ATA members can use the association's "reimbursement central" area of the website to keep abreast of the latest changes in laws and telemedicine reimbursement policies among payers.
- Before submitting claims to a payer, request information on its telehealth coverage, coding guidelines and fee schedules to understand its present thinking regarding telemedicine reimbursement. Then, call the payer's claims department -- preferably a supervisor, or the supervisor's supervisor, who will invariably understand your question much better than a front-line service rep -- to glean tips for documenting care and submitting claims that are most likely to be paid.
Such payer consultations could be a double-edged sword, Moore said, because it might draw scrutiny on a provider, and possibly increase odds of claim denials. "If the payer tells you a claim is not covered, then you have to be extra careful if you go ahead and submit the claim so the payer doesn't come back to you with an allegation that you misrepresented that you have a right to payment for that service," he concluded.
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