By JEANNE PINDER and BEN GLICKMAN
Telemedicine has boomed during the Covid-19 as an alternative to in-person visits. Doctors and patients alike are finding that the virtual visit — previously often described as a pale imitation of the actual in-person office visit — is a fine way to do health care in the middle of a pandemic.
But now both doctors and patients are looking at how insurers will pay for telemedicine. Many insurers have promised to cover telehealth for the same price they pay for in-person visits, known as parity, for now. Questions remain on how long insurers will continue to cover telemedicine, and at what level.
Researchers at Harvard University partnered with healthcare software company Phreesia to study trends in in-person and telehealth visits since the pandemic began. They found that in-person visits dropped sharply — nearly 70 percent — in mid-March as cases of Covid-19 began to rise in the United States. Meanwhile, the number of telehealth visits spiked.
As pictured above, telehealth visits sharply increased when the pandemic first hit, but have since begun to slowly decrease again. The number of telehealth visits is expressed as a percentage of the number of “baseline” visits, which is the total number of visits that Phreesia documented in the week of March 1 to 7. Dr. Ateev Mehrotra, the Harvard researcher who led the study, said in an email that the data was expressed this way because “Phreesia is extremely sensitive to showing any numbers.”
The last update to the study’s data came in mid June, before cases began to rise again in the U.S. Data has not been published on telehealth visits since cases have spiked.
In the Medicare population, the Centers for Medicare and Medicaid Services reported that 13,000 beneficiaries a week used telemedicine before Covid-19 hit; in the last week of April, nearly 1.7 million beneficiaries used telemedicine.
Was the embrace of telemedicine a surprise?
“I wasn’t surprised at all because I wanted to do this forever,” Dr. Danny Sands, assistant professor at Harvard Medical School and a faculty physician at Beth Israel Deaconess Medical Center in Boston, said in a video interview. “It was the payers that weren’t supporting us to do this. I can be very clever in the ways I take care of patients, it won’t be in the office frequently, I’ll be calling them at home, doing video and so on. That makes a lot more sense for me, and for my patients, and I can take care of more patients that way. It makes sense all around. But the problem is that health plans haven’t been paying for it until they were forced to.”
While telemedicine has boomed with the pandemic, the payment picture is complicated.
One of the first steps Medicare, the program for older Americans, took in response to Covid-19 “was to temporarily expand the scope of Medicare telehealth to allow Medicare beneficiaries across the country — not just in rural areas — to receive telehealth services from any location, including their homes,” Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, wrote in an article in Health Affairs. “CMS also added 135 allowable services, more than doubling the number of services that beneficiaries could receive via telehealth. Examples include emergency department visits, initial nursing facility and discharge visits, home visits, and physical, occupational and speech therapy services. Medicare also ensured that health care providers like physicians were paid for these telehealth services at the same payment rate as they would receive for in-person services.”
But different private insurers have different payment policies. The states have different payment policies under their Medicaid programs for low-income Americans. And there are different types of telehealth — a regular video visit by Zoom, for example, or, a visit on a proprietary platform that requires both parties to be HIPAA-compliant, or a phone visit. Many doctors that we talked with said that video visits are paid at a higher rate than a plain phone call; no one that we talked to had been paid for an email or text with a patient.
Quick changes, with little notice
The picture can change quickly. TennHealth, the Tennessee Medicaid provider, said it would pay for telemedicine visits through June 30 and would then require in-person visits, a speech therapist from Tennessee said in a phone interview. Doctors and clinics made plans to return to the office because they wouldn’t get paid otherwise; then TennHealth expanded their payment for telehealth through Aug. 29 on very short notice, she said. Speaking on condition of anonymity, she said, “Each insurance provider makes their own date, and they’ve been changing every so often too. It’s a beast to stay on top of it all.
“Some of the insurance companies end coverage before then, like Cigna is ending coverage on 7/31. Plus, there’s a small amount of clients who are refusing teletherapy because they prefer in-person,” she added.
In New York State, Gov. Andrew Cuomo declared on March 14 that insurance co-payment would be waived for telemedicine visits, as a way of keeping people home and out of their doctors’ offices. But state regulations govern fully insured plans, not self-insured plans, which are governed by federal law. So there has been a lot of confusion, with patients getting charged a co-pay and doctors unsure what they’ll be paid. Caroline Lewis wrote about the messy situation for our partner Gothamist.com, with one doctor saying the fact that his patient “heard Cuomo say telemedicine visits are free doesn’t make them so.””
‘It’s all over the place’
It appears to be common that doctors don’t know who’s paying what.
“It’s all over the place,” Dr. Jesse Hackell, vice president and chief operating officer of Pomona Pediatrics in Pomona, N.Y., said in a video interview.
“In New York, they started out saying it would be paid until June or July. Most of the payers at least have committed to paying until the end of September now. If you’re dealing with a dozen or 15 payers, you’re trying to keep track of whose latest update or guidance is changing. I’m vice president of the New York State chapter of the American Academy of Pediatrics, and I chair the Pediatric Council, which works to help pediatricians deal with insurance companies. We’ve been sending out regular updates that as of this day, one particular insurance company will extend their telehealth payment till September 4, and somebody else until September 30. We don’t have a lot of recourse — they decide that on this day they’re going to stop paying for it.
“So people will be forced to go back to the office to provide care if they expect to get paid. And then you have the problem with people not wanting to come to the office, so you end up with denied care or delayed care or inadequate care. And that impacts the health of kids going forward.”
Hackell said he had heard many reports of doctors not being paid at parity or not being paid at all for telemedicine visits. “The commercial payers in New York seem to be doing pretty well with paying at parity,” he said. “It’s some of the Medicaid managed care plans that are not yet paying at parity. As friends have said, as a physician, I have to follow the rules or I go to jail. If the insurance company doesn’t follow the rules, they go to the bank.”
USA Today reported that insurers are looking to scale back coverage of telehealth to pre-pandemic levels, but were forced to continue coverage because of surges in cases. Insurance companies have set expiration dates for telehealth coverage, but these dates have been incrementally pushed back. For example, Blue Cross Blue Shield of Texas originally had set an expiration date at the end of May, but after several delays has set a new date in August.
Errors in processing
Susan Null, cofounder of Systemedic, Inc., a medical billing and patient advocacy company. said it’s very confusing. “We have noted many errors in processing of their telemedicine visits: denials for no telemedicine coverage, cost-sharing when there should be no cost-sharing, processing at the incorrect allowed amount,” Null said in an email interview. “While the intent has been to cover these costs, the actual implementation has severely lagged behind, with systems not updated with the correct information and reps who have no idea what the coverage is supposed to be. On top of that, each insurer has changed the way they wanted the claims billed, so many, many claims needed to be resubmitted because the rules of the game were changed midstream. We have spent hours on the phone with the insurance companies to get them to process the claims correctly. While they have gotten better about this, there are still errors. I am certain that most providers are not putting in the time and effort that we have in order to correct the processing, which means there must be a significant number of people getting bills they shouldn’t be getting.”
In New Jersey, almost all the Medicaid is Medicaid managed care, meaning that it’s run not by the state but by a Managed Care Organization (MCO) often a private insurer running the Medicaid program under contract from the state, Dr. Jill Stoller, a pediatrician at Chestnut Ridge Pediatric Associates in Montvale N.J., said in a phone interview. “But it is still dictated by what the [Centers for Medicare and Medicaid Services] says,” she said. “Once the feds said it should be paid at parity, the commercial plans followed suit, because the Trump administration asked them to. At some point, C.M.S. could say you don’t have to pay telehealth at parity,” she said. She also said the commercial insurers are pushing ahead their deadlines — initially they said they would pay until June 30, she said, but now in New Jersey telehealth is paid at parity until Sept. 30.
Stoller said her group has recently renewed two new contracts with private insurers that do have telehealth parity, “the same payment for telehealth as in-person visits going forward,” she said. “That’s something every provider should ask for going forward.” Contract renegotiations take place on a regular basis, of course, and the next renewal might be different. She said her group, with 40 providers, has some clout in negotiating that a smaller group might not have.
“If Covid continues as everyone expects it to, they’ll have to extend telehealth,” she said. “It doesn’t cost more money. Instead of a sick visit in the office, it’s a sick visit at home.”
Anthem Blue Cross, based in Indianapolis, says it covers one in eight Americans for health insurance. In June, Anthem announced that it would continue to waive cost shares for telemedicine, “including telephonic visits,” until Sept. 30 for fully insured employer plans, individual plans, Medicare Advantage plans, group retiree plans and Medicaid plans “where permissible.” Anthem is also expanding telemedicine to some physical, occupational and speech therapy as well as waiving cost share for “TeleDentists,” an in-network provider with Anthem delivering online and mobile app teledentistry.
Cigna, based in Connecticut, updated its virtual care billing guidelines to waive copays for any Covid-19 related services and cover telehealth services at parity with in-person visits. Cigna said that its temporary guidelines will expire on July 31, after the federal public health emergency expires.
How the money works for Medicare
The Centers for Medicare and Medicaid Services released new policies relating to telehealth services. C.M.S. expanded coverage of telehealth, allowing any Medicare providers to be reimbursed for telehealth visits at parity with in-person services. For example, Medicare would reimburse the same amount — $53.81 — to a Manhattan doctor for a basic outpatient check-up, whether it is done in-person or over a video call.
C.M.S. has made clear that these guidelines are temporary, but has not given a specific date that they will expire.
Billing for telehealth visits is based on the length of the visit, while billing for in-person is typically based on the number of examinations, medical history taken and procedures performed. The basic outpatient check-up described above is supposed to last 10 minutes. That same visit in-person is “recommended” to last 10 minutes, but a doctor could, in theory, bill a patient for a more expensive check-up because they performed more procedures in the same 10 minute slot.
Medicare also covers visits called “virtual check ins,” which are described by the agency as “brief communication services” between doctors and pre-established patients. These virtual check ins are similar in length to certain check-ups, but are reimbursed for significantly less. A 10 minute virtual check in would be reimbursed for $17.71. Specific reimbursements can be found here.
Insurers have their own telemedicine services
Doctors also complain that insurance companies have their own telehealth providers — national giants like Teladoc and Doctor on Demand — and they try to steer patients to those contracted services, sometimes with disastrous results.
“There are some horrible telehealth programs out there, even ones run by insurers,” Stoller said. “You call and say you have a sore throat, and they call in antibiotics for you. Some really bad medicine happens that way. It’s often free to the patient — say, no co-pay with Aetna’s telehealth provider. So you get sucked into it. And then there’s a second visit where we need to fix what was messed up.
“Telehealth needs to be done in the patient’s medical home — I know the patient, have the chart, know the history, and can do appropriate follow-up.”
Many doctors have been doing primary care using telehealth as a matter of course, well before the pandemic. Dr. Jeffrey Gold of Gold Direct Care in Marblehead, Mass., practices in the direct primary care model. D.P.C. doctors have a membership of patients who pay a fixed monthly rate — in Gold’s case, from $40 to $135 monthly — for free office visits, telemedicine and reduced prices on things like prescriptions and MRI’s.
For Gold, the immediate boom in telehealth that came with Covid was not a big deal. “We were able to treat a lot of our patients through video, phone, email, stuff that we’ve been doing in the D.P.C. model for 5 to 10 years. very successfully,” he said in a video interview. But for others who were unused to telemedicine, he said, ‘It was kind of like a light dawned: not everyone has to come in for a visit so that a claim can get filed with insurance when you take that insurance piece out of primary care.” See his full interview here.
Will telemedicine continue to be as popular as it was in the first days of the pandemic? Already in some places, patients are comfortable enough in going back to the doctor’s office that telemedicine has dropped off. And yet doctors say it’s never going to go back to the way it was, when telemedicine was comparatively rare.
“I think there’s no going back, to some extent,” Sands said. “There will be pushback from payers. All this stuff’s going to have to be worked out. But the genie is out of the bottle now. And people realize this is a good thing. I mean, heck, it’s even good for the environment, right? Because we’re not driving. There’s so many good things about this.
“But let’s say that health plans say, oh, there’s too much too much fraud here, or it’s costing us too much. We’re not going to pay for it, or we’ll pay less. What are medical practices going to do? I think so much of this is going to be driven by money.”