Difference between revisions of "Telemedicine reimbursement"

From Clinfowiki
Jump to: navigation, search
(Telemedicine, Reimbursement)
 
(Telemedicine Reimbursement and Business Models)
Line 70: Line 70:
  
 
(6) This section does not require a health benefit plan to reimburse a provider for a health service that is not a covered benefit under the plan or to reimburse a health professional who is not a covered provider under the plan.
 
(6) This section does not require a health benefit plan to reimburse a provider for a health service that is not a covered benefit under the plan or to reimburse a health professional who is not a covered provider under the plan.
 +
 +
By Yair Lurie

Revision as of 05:25, 1 March 2011

Telemedicine is slowly becoming widely recognized as both cost and clinically effective. Insurance reimbursement varies from state to state. One of the main factors hindering the widespread adoption of telemedicine is that much of the services are not being adequately reimbursed. Reimbursement rates and percentages of cases that are being reibursed for are not being tracked well. In some cases such as a Grande Ronde Hospital, all their cases have been reimbursed. While at Palm Drive Hospital in Sepastopol, CA only about 10% of their cases are being reimbursed. When developing a business case for telemedicine, it is important that other reimbursements streams be evaluated. Here are some options: 1. Reimbursement: Federal, State and Private Insurance Reimbursement. See list of CPT codes and State regulatory requirements below. 2. Per Click: A Referring site should consider paying a 'per consult' or 'per-click' payment scheme. For example, when contracting for Dermatology services... 3. On-Call Payment. in example when contracting for a Remote ICU service. 4. Win-Win Payment. In some cases the increased number of referrals to the Referral site (hub) from the Originating site (spoke) can support the service. For example in the case that a Hub wants to provide Stroke Services to a Spoke site (rural health care facility), the increased number of referrals and procedures itself is enough of an incentive for the Hub site to offer the services for free. In many cases the Hub site can afford to pay for the telemedicine equipment. The Spoke site wins in by being able to keep some of their patients and having them treated on-site rather then loosing those patient days.


(Still being edited. ...Under development......Hope to have article finalized soon.......)



This article attempts to outline both Federal, State and Private Insurance guidelines and policies.

Federal Coverage:

CMS finalized their proposals to add the following requested services to the list of Medicare telehealth services for CY 2011: § Individual and group kidney disease education (KDE) services (HCPCS codes G0420 and G0421, respectively); § Individual and group diabetes self-management training (DSMT) services, with a minimum of 1 hour of in-person instruction to be furnished in the year following the initial DSMT service to ensure effective injection training (HCPCS codes G0108 and G0109, respectively); § Group medical nutrition therapy (MNT) and health and behavior assessment and intervention (HBAI) services (CPT codes 97804, and 96153 and 96154, respectively); § Subsequent hospital care services, with the limitation for the patient's admitting practitioner of one telehealth visit every 3 days (CPT codes 99231, 99232, and 99233); and § Subsequent nursing facility care services, with the limitation for the patient's admitting practitioner of one telehealth visit every 30 days (CPT codes 99307, 99308, 99309, and 99310).

Furthermore, CMS is revising §410.78(b) and §414.65(a)(1) accordingly. Specifically, the agency is adding individual and group KDE services, individual and group DSMT services, group MNT services, group HBAI services, and subsequent hospital care and nursing facility care services to the list of telehealth services for which payment will be made at the applicable PFS payment amount for the service of the practitioner. In addition, CMS reordered the listing of services in these two sections and removed "initial and follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals and SNFs" in §410.78(b) because these are described by the more general term "professional consultations" that is in the same section. Finally, CMS is continuing to specify that the physician visits required under §483.40(c) may not be furnished as telehealth services.

The telehealth originating site facility fee was raised to $24.10.

The full final rulemaking is available at http://www.ofr.gov/OFRUpload/OFRData/2010-27969_PI.pdf with the major telehealth section from pages 486 to 526. There are other provisions addressing more specific forms of telehealth, such as cardiac event monitoring.

This final rule is scheduled to be printed in Federal Register on November 29, 2010.


California:

California law mandates that all health care service plans cover services that can be adequately provided through telemedicine. California Health and Safety Code, Section 1374.13, lists the standards which health care service plans must meet and requires that the Medi-Cal managed care program plans also cover telemedicine services.



Oregon:

In 2009, the Oregon State Legislature passed Senate Bill 24[1] to join the states specifying that insurance plans cannot discriminate against otherwise covered services that are provided by a telehealth method. Section 743A.058 of the Insurance Code of Oregon Revised Statutes reads as follows:

743A.058 Telemedical services. (1) As used in this section:

   (a) “Health benefit plan” has the meaning given that term in ORS 743.730. 
   (b) “Originating site” means the physical location of the patient receiving a telemedical health service. 
   (c) “Telemedical” means delivered through a two-way video communication that allows a health professional to interact with a patient who is at an originating site. 

(2) A health benefit plan must provide coverage of a telemedical health service if:

   (a) The plan provides coverage of the health service when provided in person by the health professional; 
   (b) The health service is medically necessary; and 
   (c) The health service does not duplicate or supplant a health service that is available to the patient in person. 

(3) An originating site for a telemedical health service subject to subsection (2) of this section includes but is not limited to a:

   (a) Hospital; 
   (b) Rural health clinic; 
   (c) Federally qualified health center; 
   (d) Physician’s office; 
   (e) Community mental health center; 
   (f) Skilled nursing facility; 
   (g) Renal dialysis center; or 
   (h) Site where public health services are provided. 

(4) A plan may not distinguish between originating sites that are rural and urban in providing coverage under subsection (2) of this section.

(5) A health benefit plan may subject coverage of a telemedical health service under subsection (2) of this section to all terms and conditions of the plan, including but not limited to deductible, copayment or coinsurance requirements that are applicable to coverage of a comparable health service provided in person.

(6) This section does not require a health benefit plan to reimburse a provider for a health service that is not a covered benefit under the plan or to reimburse a health professional who is not a covered provider under the plan.

By Yair Lurie