One of the most common questions we hear when speaking with potential customers and business partners are: “Is it covered by insurance?” The simple answer is: “Yes, in many cases.” But, as with most things in healthcare, the answer is more complex.
Most states now have telemedicine parity laws—these laws dictate what types of telemedicine must be covered by insurance, and sometimes, what the reimbursement rate should be for those visits. The types of telemedicine covered include not only telemedicine categories, such as store-and-forward versus asynchronous, but also may even have different rules for different specialties, with mental health being the primary example.
For instance, laws may address real-time video visits but not store-and-forward visits. Laws may address coverage for follow-up care but not the initial diagnosis. Laws may dictate that the insurance reimbursement rate must be the same for in-person visits as for telemedicine visits, or they may leave the exact reimbursement flexible.
In addition to mandated reimbursement and coverage, insurance companies themselves maintain separate divisions that may maintain separate insurance policies for each state. So if one insurance company reimburses store-and-forward telemedicine visits at one rate in one state, that is not necessarily the case for a different state. In addition, some insurance companies and self-insured organizations view telemedicine as a competitive advantage—a way to reduce healthcare costs and improve population health. Thus, regardless of state laws, these forward-looking entities may decide to always reimburse telemedicine. They may even offer telemedicine visits for free to their members, going beyond their state’s minimum requirements.
Unless the clinic only accepts cash or telemedicine is explicitly not covered in their insurance contract, either the telemedicine vendor or practice has to deal with insurance. For virtual follow-ups, the clinic will already have the patient insurance information on file. In this case, assuming the telemedicine co-pay and payment schedule from the insurance company is already known, the medical staff can directly set the patient’s co-pay when scheduling a telemedicine visit. For patient-initiated visits, the telemedicine software must gather the patient’s insurance information directly from the patient. Then, either the clinic staff or the telemedicine vendor must determine eligibility and submit the insurance claim.
We hope that in the next several years all insurance companies will provide eligibility and co-pay details in real-time. This will benefit the patient because they will know upfront how much a virtual visit will cost. Currently, if the insurance eligibility and co-pay details are not already known, the clinic must submit the claim before knowing the reimbursement amount and patient portion of the visit. Since in these cases the final charge may not be determined until days or weeks later, we recommend alerting the patient upfront what their maximum financial responsibility could be.