Medicare reimbursement and payment for services is a bit more complex. There are more rules to consider and circumstances that must be met. Here are a couple:
Live Video Is Covered
Medicare treats live video the same as an in person visit. Store-And-Forward, however, is only permitted in 2 states (Alaska and Hawaii)
This one is a bit more complex. The patient must be at an originating site which is defined as the location of the Medicare beneficiary (patient) at the time of service. It also must 1) be within a Health Professional Shortage Area and 2) fall into one of these categories:
Physician or practitioner offices
Critical Health Clinics (CAH)
Rural Health Clinics
Federally Qualified Health Centers
Hospital-based or CAH=based Renal Dialysis Centers
Skilled Nursing Facilities (SNF)
Community Mental Health Centers (CMHC)
Other considerations for Medicare’s coverage of telemedicine are:
The originating site can also charge a facility fee (since they are hosting the virtual visit). [HCPCS code Q3014]
Only some CPT and HCPCS codes are eligible for reimbursement (please check for eligible codes regularly).
Medicare does reimburse virtual visits as equal to in-person visits.
Medicare Advantage plans are more adaptable to telemedicine than traditional Medicare.
Medicaid is quickly adopting telemedicine as a legitimate form of healthcare and the numbers back it up.
46 states reimburse for some form of live video (states without = IA, MA, NH, RI)
26 states will reimburse for transmission, facility fee or both
14 states reimburse for remote monitoring
9 states reimburse for store-and-forward (not counting states that only reimburse for tele-radiology)
Even though the state may have programs in place, many states programs determine what will qualify for reimbursement. Please make sure to check your state’s program policies to confirm what is and is not reimbursable.
Certain programs (states) may have certain requirements for patient use of telemedicine. For example, the patient may need to be at an established medical site in order to receive the care. Physicians may need to provide proof that the patient had issues receiving in person care in order to receive reimbursement.
Private Payers (i.e Major Healthcare Providers) may say they cover telemedicine, they may be policy specific. (Ex. better policy equals telemedicine coverage) Please contact your commercial payers and verify their telemedicine coverage regarding payment for services.
Reimbursement rates differ from state to state and are also affected by your agreed upon pricing. Speak with your payers to find out for sure. (most seem to reimburse for the same amount as in person)
Telemedicine & Parity
Telemedicine is fast becoming covered across America by private payers. As of now there are 29 states (+Washington D.C.) with telemedicine parity laws and 8 more with proposed laws in the works.
What is a telemedicine parity law exactly?
Parity means equal. Equal means that private payers or insurance companies have to treat telemedicine care the same as an in-person visit. Consequently this means that telemedicine is becoming even more prevalent across the country, and being viewed in equality with physical examinations or diagnosis.
The parity laws do differ by state, except covering video consultations, but you need to know what your specific state’s law is.