Healthcare reimbursement has not kept up with the practice opportunities found in telehealth. The irony is that telemedicine has been around for three decades. Yet government entities, including CMS, have failed to keep up, and their outdated requirements and unwieldy reimbursement patterns have slowed widespread telemedicine adoption. Providers have been confused, frankly, about how these visits fit their workflows as well as on the best methods for reimbursement.
But there are a number of indicators that the government and private payer community are shifting to focus more closely on providing reimbursement for virtual visits. Health strategist Lisa Remington has joined others in the healthcare community that are optimistic that the tide is finally turning, stating, “Telehealth is finally finding its place in the healthcare delivery system.”
As a result, there were 210 legislative initiatives launched in 2017 that were tied to telemedicine. Most had to do with lifting some of the regulatory restrictions that have been thwarting providers with unnecessary roadblocks to implementing the service – including how they get paid.
This article will look at how 2018 is shaping up to be the year of telemedicine. What changes to reimbursement can clinical providers expect in the orthopedic space and in other specialty areas planning on introducing or maintaining a telemedicine program?
CMS and Telemedicine 2018
CMS created a chronic care management (CCM) clinical service category back in 2015. In January this year, Medicare began allowing reimbursement for “Remote Patient Monitoring” tied to off-site tracking of chronic patient conditions. This code was designed to provide better reimbursement for remote monitoring of diabetes, heart disease, or any other long-term debilitating disorder.
According to the Remington Report, the 2018 Physician Fee Schedule recently added or changed at least eight new codes for telemedicine services, including:
- HCPCS G0296 for lung screening with low dose tomography.
- HCPCS G0506 for chronic disease care management and planning.
- CPT 90785 for “interactive complexity” stemming from communication difficulties during a psychiatric exam or treatment.
- CPT 90839 and 90840 for remote crisis psychotherapy.
- CPT 96160 and 96161 for health risk assessments
- 99091 is now unbundled allowing for providers to be separately reimbursed for the review of health data that was generated by a remote visit.
It is this last code adjustment to the Physician Fee Schedule that is particularly exciting. It prompted the Connected Health Initiative (CHI) to issue a press release calling the CMS rule change “a huge victory for telehealth innovators, connected device makers, pioneering physicians, and patients across America.”
The shift toward improving provider reimbursement for telemedicine is affecting other government healthcare reimbursement programs, as well, including:
- MACRA MIPS
Another shift in reimbursement for telemedicine has occurred under MACRA’s (Medicare Access and CHIP Reauthorization Act of 2015) Quality Payment Program. Under this program, clinicians can participate in APMs (Advanced Alternative Payment Models) or MIPS (Merit-based Incentive Payment System) reimbursement. Doctors participating in MACRA MIPS can now receive ACI (Advancing Care Information) points for using telemedicine to perform patient education, reviewing patient history, or monitoring patient care.
- Medicare Advantage
Medicare Advantage plans are expected to shift their coverage to include telehealth in 2020 beyond what is already covered in Part B. While the Secretary is still soliciting comments, it should provide additional service options for seniors and additional revenue streams for clinicians.
- Accountable Care Organizations
Eligible ACOs are expected to expand telemedicine requirements beginning in 2020 by loosening restrictions on the home as an eligible originating site while dumping Medicare’s geographic restrictions on originating locations.
Reimbursement for telemedicine visits can vary widely, but 48 states and D.C. do offer some sort of telemedicine payment. In fact, many states offer expanded visits and reimbursement that outranks Medicare! As of the writing of this blog, at least 25-states document the home as an originating site, while others don’t have any patient setting requirements.
In the case of private payers, it is important to note that every major insurance carrier already offers reimbursement for telemedicine. They’ve been ahead of the curve in recognizing telemedicine as an effective means of reducing costs while improving the quality of care.
The Remington Report says that the next few years will show an unprecedented widening of telemedicine reimbursement rules:
New rules to encourage use of telehealth services under Medicare is a priority at the Centers for Medicare & Medicaid Services (CMS), Administrator Seema Verma told the National Rural Health Association's Policy Institute meeting in Washington. “This year you are going to see a lot more from us in our payment rules,” in particular addressing the health needs of underserved areas.
Telemedicine Future State
“The ballooning costs of healthcare act as a hungry tapeworm on the American Economy.”
Part of the impetus behind what seems like a sudden push toward making telemedicine a lucrative option for clinical providers is that the United States is expected to undergo a critical shortage of providers by 2030. The Association of American Medical Colleges is expecting shortages of more 100,000 providers. An aging population and population growth, as well as a lag in the number of new physicians entering the workforce, will create unprecedented provider shortfalls. According to the study they commissioned:
- The primary care shortage will reach somewhere between 8,700 to 43,100 physicians by 2030.
- Non-PCPs of both surgical and medical specialties are expected to range between 33,500 and 61,800.
- Surgeons, in particular, will see a shortfall of up to 29,000 by 2030.
The American population is predicted to grow by 12% in the next 12 years, and at the same time, the number of U.S. residents aged 65 and up will increase by 55%. All of these issues have created a future state of uncertainty in the areas of quality and healthcare delivery.
To add to this strain, CNN Money reports that the costs of providing healthcare are skyrocketing, from 5% of the economy in 1960 to 17.9% by 2016. By 2025, however, projects place healthcare deliver at almost 20% of the American economy.
Today, there is enough clinical evidence to show that telemedicine can help healthcare providers cut costs while improving access to care. The technology can help practices streamline efficiencies in order to keep up with demand. Government payers recognize that this technology is one solution for averting the coming crisis.
OrthoLive has a telemedicine solution for orthopedic providers. Call us and expand your reimbursement opportunities.