Telehealth Predictions: Access, Reimbursement & Fraud

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HERE IS HOW

On July 16, Rep. David Schweikert (AZ-06), Co-Chair of the Congressional Telehealth Caucus, along with caucus Co-Chairs Rep. Mike Thompson (CA-05), Rep. Peter Welch (VT-AL), Rep. Bill Johnson (OH-06), and caucus member Rep. Doris Matsui (CA-06), announced the introduction of the Protecting Access to Post-COVID-19 Telehealth Act. Inspired by the new bill, along with a surprisingly supportive report from the Centers for Medicare and Medicaid Services (CMS), predictions regarding telehealth access, reimbursement (including telehealth CPT codes), and fraud are now possible.

“This unprecedented pandemic has proven that telehealth not only works, but that it’s essential,” said Welch. “Prior to the coronavirus pandemic, there was still some question as to whether telehealth could be an effective alternative to going to the doctor’s office. The answer is now clear: unequivocally, YES,” said Johnson.

More Evidence Supporting Positive Telehealth Predictions

More evidence for positive telehealth predictions recently surfaced in an important publication by the Centers for Medicare and Medicaid Services (CMS) entitled, Early Impact of CMS Expansion of Medicare Telehealth During COVID -19, and dated July 15, 2020. It presents a well-considered evaluation of telehealth pros and cons, telehealth predictions, and also identifies significant administrative changes needed for pivoting to telehealth for many of the services that have traditionally been delivered in-person.

Why Medicare Decisions Are of Relevance to Telehealth Predictions

Serving as the nation’s largest insurer and a source of sustained data-gathering efforts, Medicare has often led the United States with changes that are widely adopted by other insurance carriers. In a previous article entitled, Waiting to Exhale about Telehealth after COVID-19, Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS) was cited as saying that she “can’t imagine going back” to the pre-COVID telemedicine model. She has since also discussed how the pandemic is fueling the “rapid explosion” of telehealth visits. Since then, in its Early Impact of CMS Expansion of Medicare Telehealth During COVID -19. CMS announced the details of its current evaluation of the sustainability of long-term telehealth and related technologies to safely accommodate patient health care needs in these three primary areas:

• Access to care versus health outcomes through the use of telehealth after COVID-19
• Medicare payments for telehealth and the need for clarity regarding telehealth CPT codes
• The healthcare delivery system in general and how it has been vulnerable to telehealth fraud

Increased Access to Healthcare Systems

In response to the pandemic, CMS expanded coverage of telehealth services to practitioners’ new patients as well as their existing patients to reduce exposure risks to both patients and providers everywhere. CMS is currently evaluating incoming data on whether or not allowing new patients with urgent needs to continue to be seen via telehealth “will result in the best possible outcomes.” Telehealth predictions for the continued access to services by beneficiaries are quite positive. The Early Impact of CMS Expansion of Medicare Telehealth During COVID -19 states:

• The data have shown that telehealth can be an important source of care across the country, not just for those living in rural areas. Additionally, the immediate uptake in telehealth demonstrates the agility of the health care system to quickly scale up telehealth services, so that health care providers can safely take care of their patients while avoiding unnecessary exposure to the virus.

Telehealth.org Telehealth Prediction #1

Telehealth.org predicts is that telehealth access is going to be demanded by the consumer public, who has now experienced the many benefits of telehealth delivered to the home during COVID-19. In spite of powerful lobbies that have created previously insurmountable barriers to telehealth expansion, insurers will be hard-pressed to deny services to an informed public. Legislators will be forced by consumer demand to pass laws that allow affordable healthcare to be quickly and conveniently be delivered from the convenience of one’s home. Telehealth will be considered a right for everyone, and not just an option for the elite.

Reimbursement through Medicare

During the pandemic, Medicare has been paying clinicians the same rate for telehealth visits as is paid for in-person visits in a hospital setting.  CMS is evaluating if permanent adjustments should be made regarding the resources/costs involved in telehealth visits versus in-person care. With COVID putting a serious damper on the use of medical and behavioral office space, these issues are also likely to be calculated into their equation and telehealth predictions.

For more information about telehealth changes since the beginning of COVID, see this Telehealth Primer. Also, see What about telehealth billing?” Answers to Your Questions About Billable Telehealth Services and Telehealth CPT Codes during COVID and COVID-19 Telehealth Reimbursement Update for details of current CPT codes.

Telehealth.org Telehealth Prediction #2

Telehealth.org predicts that telehealth CPT codes will increase in number but that professional reimbursement rates will decline as insurers calculate their cost savings if patients don’t visit professional offices to obtain care. Decreasing fees will become the norm, making it even less feasible for the independent practitioner to afford a professional office. Only well-funded, problem-specific services will be able to keep their professional doors open, while many mild types of disorders will be treated by professionals working from their homes deliver care to patients who stay in theirs.

Fraud in Healthcare Delivery Systems

In an effort to protect Medicare beneficiaries and associated expenditures from fraudulent acts, CMS is examining data to identify fraudulent practices that might be occurring to maximize payment. Examples include: providing shorter telehealth visits than when meeting in-person, and/or billing for an excessive number of visits per day. The current evaluation then, is addressing whether the expansion of telehealth services leads to a need for “addressing the potential for fraud and abuse in telehealth”….

Telehealth Prediction #3

Telehealth.org predicts that many more telehealth-based crimes are currently underway because well-intentioned practitioners and their systems are unaware of how their lack of training creates danger for vulnerable patients. As cybercrime cases surface, the call for professional training will increase and eventually become mandatory. The importance of Telehealth Certification will rise in the marketplace, as employers seek health care professionals who can deliver evidence-based, privacy-protected, clinical care through telehealth systems with competence rather than guesswork.

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