10 Facts: Billing Telemedicine with Private Payers

Lea Chatham January 5th, 2016

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By Teresa Iafolla 

Whether you’re just getting started with telemedicine or considering adding it to your practice, conquering your telemedicine billing policy is a big step. If you’ve decided to forgo the cash-pay model for telemedicine visits, you’re in the realm of telemedicine reimbursement–a tricky spot if you don’t know all the facts.

Since the three major payer types (Medicare, Medicaid, Commercial) have different guidelines when it comes to getting reimbursed for telemedicine, it helps to review the trends and rules for each one individually. Last month, I did a review of things to know if you’re planning to offer telemedicine to your Medicare population.

Now, it’s time to review what telemedicine looks like with commercial payers. Which private payers cover telemedicine? Do they have the same types of restrictions as Medicare? What kinds of specialties and services do they cover? Do they use the GT modifier too?

Here are the 7 things you should know about telemedicine and commercial payers. Tweet this Kareo story

  1. If your state has passed a telemedicine parity law, it means commercial payers have to cover telemedicine services in your state. A telemedicine parity law is a state law that mandates private payer (and some cases, Medicaid) coverage for telemedicine services, in the same way as in-person medical services. Some states do have restrictions on this (for instance, see Arizona’s partial parity law), so it’s worth reading the fine print. But basically, if your state has a telemedicine parity law, it’s good news for you. Currently, 29 states and DC have telemedicine parity laws.
  2. The Big Five payers all have some sort of telemedicine coverage. Our team has called around to the big five commercial payers (Aetna, Humana, Blue Cross Blue Shield, Signa, United Healthcare) and they all say they cover telemedicine. However, that coverage can vary state-to-state and is often policy-dependent. So while a patient with the top-tier Aetna plan in Maryland may have telemedicine visits listed as a covered service, another patient with a lower-cost plan may have it excluded.
  3. The best way to know if telemedicine is covered by an insurance policy is to call the payer and verify. Since the policy and billing guidelines around telemedicine are still evolving, the best way to confirm a commercial payer’s rules is to call and get a rep on the record. Our team has created this telemedicine insurance verification form that you can use to document the call. It includes the specific CPT codes to ask about, and other potential restrictions (is there a monthly limit to the number of telemedicine visits the patient can do?) Make sure to always record the reference ID from the call on that form. As our eVisit billing expert likes to say – that’s your golden ticket! If the rep from that payer tells you the service is covered and to use a certain billing code on the record, they have to honor that. If at any point you need to go back to hem, all you have to do is read off that reference number.
  4. While some commercial payers will cover store-and-forward and remote patient monitoring telemedicine services, the predominant type of telemedicine is live video. Most private payers are moving first to cover live video telemedicine as a way to do remote doctor visits with patients. Most of their guidelines, as well as state telemedicine parity laws are focused on live video.
  5. If a commercial payer provides coverage for telemedicine, it generally will reimburse for standard evaluative and management services. In many cases we’ve found that a live video telemedicine visit would just be billed with the appropriate E&M code and the GT modifier to show the service was done via telemedicine. However, some payers may advise you to use the telemedicine-specific code 99444. Some commercial payers also cover a much wider range of services, especially related to mental health and chronic care, but E&M services are the default. Again, you have to verify with the payer what their rules are. If you’re curious and looking for an example from a specific payer, check out this telehealth policy from BCBS North Carolina.
  6. Commercial payers will generally reimburse at the same rate as the corresponding in-person medical service. This is especially true if your state has a telemedicine parity law and you’re billing the standard E&M code with a GT modifier tacked on. In most cases, the payer will just reimburse you according to your negotiated physician fee schedule.
  7. The future is looking bright for commercial payers and telemedicine. Many of the big commercial payers have been doing pilot programs with telemedicine to test the touted benefits of cost-savings and care outcomes. As these programs produce results, payers are likely to revise their 2016 policies to offer much broader coverage of telemedicine services.

Want to know more about telemedicine and private payers? You can always send me an email or checkout the reimbursement page on eVisit for more information.

About the Author 

Teresa Iafolla is Director of Content Marketing at eVisit, a physician-first telemedicine solution connecting providers to their patients via secure, video chat. Teresa manages and writes for the eVisit Blog, a resource for physicians and practice managers trying to improve their practices and boost revenue. To contact Teresa with questions or comments, email tiafolla@evisit.com.

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