The Evolving Landscape of Medicare Telehealth Reimbursement Regulations

As technological advances increase, so does the complexity of implementing it into businesses, especially in healthcare.  Healthcare organizations must comply with a myriad of regulations to implement technology.  Here we discuss some of the legal issues in implementing telemedicine.   

The Centers for Medicare & Medicaid Services (CMS) governs Medicare reimbursement policies for telehealth services. Medicare pays for certain Part B services that a physician or practitioner provides via 2-way, interactive technology, or telehealth.

To qualify for Medicare reimbursement, providers must comply with the medicare telehealth policies. Medicare covers a limited set of telehealth services under specific conditions, and these policies have evolved over time, particularly in response to the COVID-19 pandemic.  In response to the pandemic, and to meet demands for remote access to health care providers, Medicare applied certain flexibility waivers to their telehealth policies. 

Generally, these telehealth flexibility waivers include:

1. Patient location: Health care providers may offer telehealth services to patients located in their homes and outside of designated rural areas.
2. Types of telehealth services covered: The Centers for Medicare & Medicaid Services significantly expanded the list of services that can be provided by telehealth. Some of these services will continue to be covered under Medicare through December 31, 2024.some text
   • Some types of telehealth services no longer require both audio and video — visits can be conducted over the telephone.
   • For details see this list of telehealth services covered by Medicare.
3. Types of eligible providers: Generally, any provider who is eligible to bill Medicare for their professional services is eligible to bill for telehealth during this period.
4. Supervision of health care providers: Health care providers may supervise services through audio and video communication, instead of only in-person.

Some of the pandemic Medicare telehealth flexibility waivers have become permanent, while others remain temporary.  The permanent flexibility waivers include:

1. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as a distant site provider for behavioral/mental telehealth services.
2. Medicare patients can receive telehealth services for behavioral/mental health care in their home.
3. There are no geographic restrictions for originating site for behavioral/mental telehealth services.
4. Behavioral/mental telehealth services can be delivered using audio-only communication platforms.
5. Rural Emergency Hospitals (REHs) are eligible originating sites for telehealth.

The temporary flexibility waivers are:

1. FQHCs and RHCs can serve as a distant site provider for non-behavioral/mental telehealth services.
2. Medicare patients can receive telehealth services in their home.
3. There are no geographic restrictions for originating site for non-behavioral/mental telehealth services.
4. Some non-behavioral/mental telehealth services can be delivered using audio-only communication platforms.
5. An in-person visit within six months of an initial behavioral/mental telehealth service, and annually thereafter, is not required.
6. Telehealth services can be provided by all eligible Medicare providers.

The Consolidated Appropriations Act of 2023 and Calendar Year 2024 Physician Fee have extended all the temporary telehealth flexibility waivers through December 31, 2024.

In 2024, specific temporary flexibility waivers were applied to utilization of telehealth in nursing facilities: 

1. CMS is temporarily expanding the definition of telehealth practitioner to include physical therapists (PT), occupational therapists (OT), and speech-language pathologists (SLP).  
2. CMS is also temporarily removing frequency limitation for subsequent nursing facility visits, indicating that physicians could continue to furnish telehealth services to nursing facility residents for visits, other than the required 30 or 60 day in-person visits required under 42 CFR 483.30.

Here are some key points regarding Medicare telehealth reimbursement:

1. Covered Services: Medicare typically reimburses for a wide range of telehealth services, including evaluation and management (E/M) visits, mental health counseling, preventive health screenings, and certain other services. During the public health emergency, Medicare expanded coverage to include additional services, such as virtual check-ins and e-visits.
2. Eligible Providers: Medicare reimburses for telehealth services provided by eligible healthcare professionals, including physicians, nurse practitioners, physician assistants, certified nurse-midwives, clinical psychologists, and certain others. During the public health emergency, Medicare also allowed reimbursement for services provided by a broader range of providers, including physical therapists, occupational therapists, and speech-language pathologists.

Provider credentialing management to ensure eligibility proves very important and a constant challenge.  Many organizations expend significant resources managing staff credentialing manually or by spreadsheets.  Organizations may find it useful to rely on credentialing automation solutions, such as those offered by Perla or other similar compliance management solution platforms, to streamline this cumbersome aspect of their business operations.  

3. Originating Site and Distant Site Requirements: Medicare typically requires that telehealth services be provided to beneficiaries located in certain types of healthcare facilities, known as originating sites, while the provider delivers services from a distant site. However, during the public health emergency, many of these restrictions were waived, allowing beneficiaries to receive telehealth services from their homes, and providers to deliver services from any location.
4. Telehealth Technology Requirements: Medicare typically requires the use of interactive audio and video telecommunications systems that permit real-time communication between the provider and the patient. During the public health emergency, Medicare provided flexibility in the types of technologies that could be used, including allowing the use of audio-only telehealth services in certain situations.
5. Reimbursement Rates: Medicare reimburses for telehealth services at rates similar to those for comparable in-person services. However, during the public health emergency, some temporary changes were made to increase reimbursement rates for certain telehealth services, including allowing reimbursement for telehealth services at the same rate as in-person services for Medicare Advantage plans.

It's important to note that telehealth reimbursement rules may vary depending on the specific circumstances and may be subject to change. For the most up-to-date information on Medicare telehealth reimbursement rules, it's advisable to consult official sources such as the Centers for Medicare & Medicaid Services (CMS).

Below is a list of common telehealth billing mistakes that organizations should avoid to help a smoother reimbursement process:

1. Incorrect billing codes: More than 100 telehealth services are covered under Medicare. However, some CPT and HCPCS codes are only covered temporarily. Using the wrong code can delay your reimbursement. This can happen for a variety of reasons, such as a misunderstanding of what code applies to what service or input error. Use the most updated Medicare billing codes for telehealth to keep your practice running smoothly.
2. Documentation: Post-visit documentation must be as thorough as possible to ensure prompt reimbursement. While there are many similarities between documenting in-person visits and telehealth visits, there are some key factors to keep in mind.some text
   1. Patient consent: Make a note of whether the patient gave you verbal or written consent to conduct a virtual appointment.
   2. Code categories: Telephone codes are required for audio-only appointments, while office codes are for audio and video visits.
   3. Time of visit: A common mistake made by health care providers is billing time a patient spent with clinical staff. Providers should only bill for the time that they spent with the patient.
   4. Store-and-forward: Many states require telehealth services to be delivered in “real-time”, which means that store-and-forward activities are unlikely to be reimbursed. You can find information about store-and-forward rules in your state.
   5. Originating sites and distant sites: Learn about eligible sites as well as telehealth policies specific to Federally Qualified Health Centers and Rural Health Clinics.

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