Maximizing Telehealth Reimbursement: Navigating The Insurance Billing Landscape

Billing insurance for telehealth services can be a complex and ever-changing process, with guidelines still in flux in the wake of the COVID-19 pandemic. While most major private payers cover telemedicine, the billing process varies from payer to payer, including Medicare, Medicaid, and private payers. It is crucial to verify coverage with the patient's insurance before their first telehealth visit, as policies and requirements differ across states and insurance providers. This includes understanding the specific CPT codes eligible for billing, place of service codes, modifiers, and any facility fees that may apply.

Verify insurance coverage before the appointment

Verifying insurance coverage before a telehealth appointment is crucial to ensure that patients can access the care they need without unexpected financial burdens. Here are some detailed steps to verify insurance coverage:

• Contact the Patient's Insurance Company: Ask the patient for their insurance information and contact the insurance company directly. Inquire about their coverage for telehealth services, including any specific requirements or limitations.
• Check State-Specific Regulations: Telehealth coverage and regulations vary from state to state. Use resources like the Policy Finder tool to stay updated on the most recent regulations in your state.
• Understand Coverage for Different Services: Telehealth services can include telemedicine (online doctor visits), health-related education, and virtual check-ins. Ask the insurance company about the specific services they cover and any associated costs.
• Review the Patient's Plan: Different insurance plans within the same company may have varying levels of telehealth coverage. Ask the patient for their specific plan details to ensure accurate verification.
• Inquire About Provider Network: Confirm that the telehealth service provider is within the patient's insurance plan network. This can impact the cost and coverage of the appointment.
• Understand Cost-Sharing: Determine if the patient will be responsible for any out-of-pocket expenses, such as copays or coinsurance. Inform the patient about these potential costs before the appointment to avoid surprises.
• Document and Confirm: During the verification process, take detailed notes and confirm all critical information. Ask the insurance company representative to review the documented information to ensure accuracy.
• Verify with the Patient: Encourage patients to verify their coverage independently by checking with their insurance company or referring to their plan documents. This extra step can help identify any discrepancies and ensure a clear understanding of their benefits.
• Consider Medicaid and Medicare: If the patient has Medicaid or Medicare, refer to the specific guidelines for these programs. Medicaid coverage and regulations vary by state, while Medicare has expanded telehealth coverage during the COVID-19 pandemic.
• Stay Informed about Updates: Telehealth coverage guidelines are subject to change, especially in response to public health emergencies. Stay informed about any updates or temporary expansions in coverage to better serve your patients.

By following these steps, you can help ensure that patients understand their insurance coverage for telehealth appointments and can make informed decisions about their care.

Ask the right questions: eligible healthcare providers, services, restrictions, etc

Billing for telemedicine can be challenging, especially with the constant changes brought about by the COVID-19 pandemic. To successfully bill insurance for telehealth, it is crucial to ask the right questions to understand the eligibility criteria, covered services, and any restrictions imposed by the insurance company or Medicare. Here are some key questions to consider:

Eligible Healthcare Providers

Ask the insurance company or Medicare about the specific healthcare providers who can bill for telemedicine services. This can include physicians, nurse practitioners, or other qualified health professionals offering evaluative and management services. Understanding the eligible provider types is essential for proper billing.

Covered Healthcare Services

Inquire about the healthcare services that can be provided and reimbursed through telemedicine. Common telehealth services often include office or outpatient visits, emergency department or inpatient consultations, and follow-up inpatient consultations. It is important to clarify which services are covered to ensure accurate billing and reimbursement.

Live Video Telemedicine Coverage

Confirm whether the insurance company or Medicare specifically covers live video telemedicine services. This is an important distinction, as some payers may have different policies for live video consultations compared to audio-only or virtual-digital visits.

Restrictions and Conditions

Ask about any restrictions or conditions that patients must meet to qualify for telemedicine coverage. For example, some payers may require an established provider-patient relationship or informed patient consent in writing. Additionally, inquire about any distance requirements between the patient and the provider that must be met for reimbursement.

Annual Limits on Telemedicine Visits

Clarify whether there are any restrictions on the number of telemedicine visits a patient can have in a given year. Some insurance companies or Medicare plans may impose annual limits on the number of covered telemedicine visits, so it is important to be aware of these limitations.

Eligible CPT Codes for Billing

Different payers may have specific Current Procedural Terminology (CPT) codes that are eligible for billing telemedicine services. Ask the payer for a list of covered CPT codes or inquire about specific codes, such as the telemedicine-specific code 99444. Understanding the eligible CPT codes is crucial for accurate reimbursement.

By asking these questions and understanding the eligibility criteria, covered services, and restrictions imposed by the insurance company or Medicare, healthcare providers can effectively navigate the complexities of billing for telemedicine services. It is always advisable to verify coverage and guidelines before providing telemedicine services to ensure smooth reimbursement and avoid claim denials.

Know the telemedicine guidelines for each payer

Knowing the telemedicine guidelines for each payer can be a daunting task, especially when dealing with the three major types of payers: Medicare, Medicaid, and private payers. The easiest way to learn what each payer requires for telemedicine billing is to call and ask the right questions. Here are some of the things you should ask:

• Which healthcare providers can bill for telemedicine?
• What healthcare services can be done via telemedicine?
• Do you specifically cover live video telemedicine?
• Are there any restrictions or conditions that need to be met before a patient qualifies for telemedicine (e.g. distance from the provider, established provider-patient relationship, informed patient consent in writing)?
• Are there any restrictions on the number of telemedicine visits patients can have in a given year?

Some payers may have concrete answers to these questions that define their telemedicine coverage. Others may just say they cover telemedicine for certain providers and not put many restrictions on it. Since these guidelines vary from payer to payer and state to state, be sure to call each payer and get their guidance.

It is important to keep in mind that the rules are changing rapidly, and the representatives at the insurance carriers may not be aware of all the changes. In addition, Medicare and insurance companies need to update their computer systems, so don't be surprised if your telemedicine claims are initially denied.

Ask about eligible CPT codes for billing

To bill insurance for telehealth services, it's important to be aware of the relevant CPT (Current Procedural Terminology) codes and ensure your team is trained on the various codes and processes for reimbursement. CPT codes are regularly updated, and Medicare regulations can change, so staying up to date is crucial to avoid billing mistakes and delays in reimbursement.

CPT codes are five-digit numbers that correspond to specific medical services provided to patients. These codes are used by healthcare providers to bill insurance companies and government programmes like Medicare for reimbursement. CPT codes for telehealth services cover a range of areas, including:

• Remote Patient Monitoring CPT Codes: These codes cover services such as remote evaluation of recorded video and/or images submitted by a patient, including interpretation and follow-up within a specified timeframe.
• Office or Outpatient Visits: CPT codes 99201-99205 and 99211-99215 are commonly used for telehealth office visits, whether for COVID-19-related or general care.
• Consultations: CPT codes for consultations can vary depending on the setting, such as emergency department consultations or initial inpatient consultations.
• Telebehavioral Health: During the COVID-19 public health emergency, Medicare and Medicaid expanded coverage for telebehavioural and telemental health services. CPT codes for these services include 90832, 90833, 90834, 90836, 90837, and 90838 for behavioural screening and diagnostic evaluation.
• Virtual Check-Ins: CPT codes for brief communication technology-based services, such as virtual check-ins, include HCPCS codes G2012 and G2010. These codes are used when a patient has a brief consultation with their doctor to address a concern without needing to visit the office.
• E-Visits: E-visits are non-face-to-face patient-initiated communications through an online patient portal. CPT codes for these services include 99421-99423 for established patients, and HCPCS codes G2061-G2063 for qualified non-physician healthcare professionals.

It's important to note that CPT codes can vary depending on the patient's insurance provider and the specific services rendered. Additionally, some CPT codes are only temporarily covered by Medicare or other insurance providers, so it's crucial to stay informed about any changes or updates to the codes.

Understand when to use the GT and 95 modifiers

The GT modifier is a coding modifier used for telehealth claims. It indicates to the insurance company that the services took place via an interactive audio and video telecommunications system. It is defined as services provided via synchronous telecommunication, which means it occurs in real-time, not asynchronously like email, and is a way of signifying a video call.

The 95 modifier is similar to the GT modifier, but there are limits to the codes it can be appended to. It was introduced in 2017 and is defined as "synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system". In other words, this is a way to describe a telehealth session.

The GT modifier was the standard for signifying telehealth claims for many years before being mainly replaced by the 95 modifier. In 2018, when CMS and Medicare stopped using the GT modifier, most companies followed suit and switched to the 95 modifier. Despite this, some insurance companies still accept and even require GT modifier claims.

To maximise your reimbursement rate, it is important to verify which of the telehealth modifiers your insurance company accepts most widely.

Frequently asked questions