Commercial payers—that is, private insurers—have been most aggressive in reimbursing for telehealth visits. Many national plans embrace this healthcare innovation and have been steadily broadening coverage through partnerships with telemedicine services companies. Amwell, for example, now covers 50 million commercial lives for telehealth visits through 30 separate major health plans. This is happy news for doctors and the systems in which they work. Their patient populations are steadily gaining telemedicine benefits, and companies like Amwell offer real-time eligibility and claims processing, letting the provider know prior to starting a telemedicine visit if the patient’s plan will reimburse them for their services.
Regulation affects the commercial payer realm as well. Today, 29 states and the District of Columbia have parity laws that mandate commercial payers to provide comparable coverage and reimbursement for telemedicine services as in-person services. This is great news for providers, as it suggests that over time telemedicine will gain parity footing with in-person consultations across the board. Beyond these laws, the high potential for cost savings in the commercial sector—an average of $126 per visit for acute care—has incentivized many plans to cover telemedicine.
All of this is not to say that the commercial realm is without issue. Payers are not universally compliant with parity regulations, and few of these laws bear teeth in terms of required dates for compliance. Telehealth coverage has grown so fast in the commercial realm because visits are less expensive, so parity reimbursement could have a chilling effect on health plan promotion of telemedicine for patients. Commercial insurers are also still grappling with issues such as building telemedicine codes into claims systems and determining their level of coverage for various specialist services, from teledermatology to telepsychiatry.
Despite all this, reimbursement through private insurance companies is the least confusing and the most promising. With national health plans such as United Health Care and Anthem advertising their telemedicine visits and coverage on television and the web, it’s clear that some powerful players stand behind telemedicine and are dedicated to making it work as an integrated part of the healthcare system, not just for patients, but also for providers iii.
Each private payer does telemedicine reimbursement a little differently. The good news is, many of the large insurance companies are seeing the benefits of telemedicine and starting to provide broader telemedicine coverage. Twenty-nine states and the District of Columbia currently require private payers to reimburse telemedicine. These states have enacted telemedicine parity laws, which require private payers to reimburse providers the same amount for telemedicine services as the comparable in-person service. To check for updates on state legislation, visit the ATA State policy center and review their helpful state legislation matrix. The big insurance carriers (BCBS, Aetna, Cigna, United Healthcare) cover telemedicine. The largest commercial payers do cover telemedicine. However, whether they will reimburse for a telemedicine service is policy-dependent, meaning one patient might be covered under their BCBS policy and another may not if their policy excludes telemedicine.
Call your payers and ask the right questions. The best way to find out telemedicine reimbursement policies from your private payers is to pick up the phone and call their eligibility and benefits department. Have a list of the relevant telemedicine CPT codes on hand (see complete Telemedicine Reimbursement Guide for the list!). Here are a few questions to ask:
- Which CPT and HCPCS codes can be completed via telemedicine?
- Are there any restrictions on the location of the patient or provider?
- Do I need to use a modifier (GT)?
- Does the reimbursement rate match the in-person rate?
- Which providers are eligible (physician, NP, PA)?
- Are there any specific notes that need to be included in the visit documentation?
Verify the patient’s insurance. Since telemedicine is policy-dependent, you’ll need to verify that the patient’s insurance does cover it. You can use a sample telemedicine insurance verification form to call up the patient’s insurance carrier and record whether or not they’re covered.