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Medicare reimbursement for telehealth

Medicare reimbursement for telehealth

In recent years, telehealth has caught fire within the medical community. Treating patients regardless of distance or physical danger in remote areas is quickly becoming routine in the United States and all over the world. In recent years, the government has begun to reimburse telehealth professionals for the cost of their operations, but the process for receiving this reimbursement can be tricky. Here’s a handy guide for asking for and receiving Medicare reimbursement for telehealth.

Medicare reimbursement for telehealth process

There are many Medicare reimbursement for telehealth guidelines within the industry, many which are still changing and being written and rewritten as more companies within the industry utilize telehealth technologies and capabilities. There is no one set of rules for receiving Medicare reimbursement for telehealth but there are a number of guidelines which you should follow for the best chance at receiving your benefits.

Identify the telehealth type

There are a number of different telehealth techniques and methods currently being employed. The range of telehealth services is vast and growing every day, so it’s important to know which type telehealth your hospital is practicing. Just a few examples of “types” of telehealth are live video for patients and physicians, software for remote patient monitoring, and remote on-call physicians. Medicare reimbursement for telehealth will be appropriate for some types of telehealth but not others; for example, live video telemedicine is currently reimbursed for live video transmission in all but two states, but store-and-forward telemedicine is rarely reimbursed.

Define telehealth utilization

For as many types of telemedicine that exist, there are unique ways to use those types. Hospitals can check in with patients after they’ve discharged them, treat minor, acute conditions such as infections or joint pain, or offer their patients the chance to consult with a specialist during a visit. Going through the Medicare reimbursement for telehealth process will become significantly easier if you know your usage type and can readily and accurately describe the ways in which telemedicine is being employed in your hospital.

Additional factors

While the type and use of your telemedicine are both crucial to receiving your Medicare reimbursement for telehealth, there are other considerations to keep in mind while navigating the Medicare landscape. First, you should know and be able to define your “origin site” and “distant site.”

Medicare reimbursement for telehelath is offered for healthcare providers at a Distant Site, to a Medicare beneficiary, the patient, at an Originating Site. The location where the telemedicine is being employed is known as the Distant Site while the patient resides at the Originating Site, which can be a tricky concept. However, the Originating Site must be in a Health Professional Shortage Area. These types of sites include:

  • Physicians or practitioner offices
  • Hospitals
  • Critical Access Hospitals
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Hospital-based Renal Dialysis Centers
  • Skilled Nursing Facilities
  • Community Mental Health Centers

Medicare reimbursement for telehealth is only offered if the patient is receiving care at one of the areas mentioned in the above bullet points. They cannot be at home or in another location when receiving the benefits of your telemedicine care. In addition, the patient must also be in a Health Professional Shortage Area, meaning there’s a scarcity of healthcare professionals in the area where the patient is being treated. To determine if your patients are in a Health Professional Shortage Area, use this CMS tool.

In addition to patient location requirements, only certain CPT and HCPCS codes are eligible for telemedicine reimbursement. Before you seek Medicare reimbursement for telehealth, research these codes to determine if your hospital is operating in one of these areas. You can also visit the CMS website, as the list of codes is subject to change every year. Also keep in mind, when billing for telehealth services, you must use the 95 modifier for commercial insurance plans and include the “GT” modifier for Medicare and Medicaid plans.

Private payers

Every private player working with telemedicine technologies uses a different reimbursement process. However, insurance companies are quickly catching on to the benefits telehealth services enable and are working to provide a broader coverage for telemedicine. Here are the most important points when dealing with private payers.

  • 29 States and DC require private payers to reimburse telemedicine. The list of states which require reimbursement is publicly available. For updates and changes to the list, visit the ATA State policy center and review their legislation matrix.
  • Many large insurance carriers – BCBS, Aetna, Cigna, United Healthcare – currently cover telemedicine. The largest commercial payers cover telemedicine, but the choice to reimburse for that telemedicine is policy dependent. This means that one patient might be covered under a policy while another is excluded under their own policy.

You can always call your private payers and make an inquiry to their eligibility and benefits department. Remember to provide a comprehensive list of CPT codes and ask specific questions such as:

  • Which CPT and HCPCS codes can be completed via telemedicine?
  • Does the reimbursement rate match the in-person rate?
  • Which providers are eligible?
  • Are there any notes which need inclusion in the visit documentation?

Lastly, verify the patient’s insurance. Telemedicine is policy dependent, meaning you’ll want to verify that the patient is indeed covered under their insurance policy. The process for this is simple and similar to checking how they’re covered in any other type of hospital visit.

Final thoughts

The last tip to master the Medicare reimbursement for telehealth process is to compile the research you’ve done and send it out to your billing staff. The billing staff will need to know the crucial information you’ve learned, such as the correct codes and rules for each payer, whether public or private. If, for whatever reason, reimbursement is not possible for your hospital, consider charging the patient directly.

This is not an ideal strategy, as patients will feel it reflects poorly on your quality of care, but there are some patients who don’t mind paying a small convenience fee for telemedicine and its benefits. Keep the fees small, about $30 to $65 per visit should be enough to cover your telemedicine costs.

Seeking Medicare reimbursement for telehealth is a lengthy, tricky process, but there are a few key pieces of information which will speed up our inquiries and set you on the road to your reimbursement. Learn more about this online or take free courses at

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