Telemedicine Reimbursement

Getting reimbursed for the telehealth services you provide is not straightforward, but Comiere will guide you. Reimbursement policies vary greatly according to the payer, and these policies continue to change as telemedicine grows in popularity.

Read on for answers to the most common reimbursement questions.

What kind of telehealth are you offering?

Reimbursement depends greatly on the kind of telehealth service you are offering. You are far more likely to be reimbursed for live video than for store-and-forward and remote patient monitoring, for example, although reimbursement for store-and-forward and remote patient monitoring is starting to increase. Refer to the Public Health Center for Connected Health Policy’s guide for further detail.

How will you use telemedicine?

Do you use telemedicine to review a patient’s condition after they have left hospital? Or do you use it to consult a specialist while assessing a patient. Maybe telemedicine is your preferred option to treat patients with minor acute conditions such as infections. Your reimbursement options will depend on your specific use case.

How does reimbursement for teleservices work with Medicare?

This is where Originating and Distant Sites come in. Medicare reimburses telehealth service providers at a distant site, whereas it reimburses Medicare patients at an originating site, which must be in a HPSA (Health Professional Shortage Area).

The patient must also be in a HPSA and must be receiving telemedicine from a legally authorized originating site in that HPSA. The originating site will also receive a facility fee for hosting the telemedicine visit.

HPSAs include:

  • Physicians or practitioner offices
  • Hospitals
  • Critical Access Hospitals (CAH)
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Hospital-based or CAH-based Renal Dialysis Centers (independent renal dialysis clinics are not included)
  • Skilled Nursing Facilities (SNF)
  • Community Mental Health Centers (CMHC)

You can check whether a health facility is in a HPSA by typing the address here.

About CPT and HCPCS Codes

Not all CPT and HCPCS codes are eligible for telemedicine reimbursement. Check the CMS website for CPT and HCPCS codes that are covered under telemedicine services.

Are you using the correct modifier?

Remember to use the 95 modifier when you are billing for telemedicine visits for commercial insurance plans. For Medicare and Medicaid plans, use the GT modifier.

How much will you be reimbursed?

The reimbursement rate you receive from Medicare for the telemedicine services you provide is calculated at the same rate as the corresponding in-person medical service, based on the current Medicare physician fee schedule. The physician fee schedule is available on the CMS website.

What about private payers?

There is no uniform approach to telemedicine reimbursement among the private payers. Fortunately, many of the bigger insurance companies are beginning to recognize the benefits of telemedicine, so coverage is starting to improve.

Washington, D.C., and 29 states oblige private payers to reimburse telemedicine. These states have introduced telemedicine parity laws, which mean that reimbursement rates payable by private payers to telemedicine providers must equal the payments they make for comparable in-person services.

The American Telehealth Association State policy center has a very useful state legislation matrix to illustrate how the different states approach reimbursement.

State Telehealth Policies

States continue to develop their own specific telehealth policy frameworks, as more and more legislation is approved. Some of these states have framed their policies in law, whereas others are dealing with issues such as definition, reimbursement policies, and licensure requirements in their Medicaid Program Guidelines. Each state’s laws, regulations, and Medicaid policies differ significantly.

Consult the Center for Connected Health Policy’s useful guide to state laws and reimbursement policies for further details.