If you’re interested in implementing telemedicine into your practice or have already done so but have questions about how to be reimbursed for the care you provide, this article will give you a basic overview of your options. We’ll also show you how to research for your specific practice, so you can know which questions you need to consider and ask.

Determining Factors for Reimbursement

The Originating Site

This is the location of the client while the services are being remotely delivered. Some of the most common originating sites are the client’s home, federally qualified health center, hospital, physician’s office, or a long-term care facility.

The Distant Site

This is the location of the healthcare provider at the time of the remote telehealth session. Common distant site locations include a hub site, specialty site, provider or physician site, and a referral site.

Your Licensure

The licenses you hold can determine if your services are eligible when they’re delivered remotely. Generally, you must be licensed in the state your client resides, although there are some interstate licensure agreements in development.

Eligible CMS/CPT Codes

The Centers for Medicare and Medicaid Services (CMS) will decide whether to approve a CPT code for reimbursement based on the category of the service provided. CPT codes are based on two categories:

Category 1 Services

Services that are similar to existing services, such as psych consults and office visits, that are already approved for telehealth delivery.

Category 2 Services

Services that are not similar to existing Medicare-approved telehealth services.

Payer Policy

Because there are no standardized parameters for reimbursement policy across all states and payers, it’s important for you to research factors such as each of your contracted insurance providers, state-specific guidelines in the states you are licensed to practice, and any relevant federal guidelines.

Federal Reimbursement: Navigating Medicare

Medicare allows reimbursement based on what type of healthcare provider you are. This includes clinical psychologists, clinical social workers, and registered dieticians.

Medicare will pay an originating site facility fee for covered telehealth services. As we said earlier, care must be provided at the proper type of originating site in a health professional shortage area (HPSA).

Authorized originating sites include physicians or practitioner offices, hospitals, critical access hospitals, rural health clinics, federally qualified health centers, skilled nursing facilities, and community mental health centers. These must be in an area (by geography, population, or type of facility) that have a shortage of mental health providers.

The Health Resource and Service Administration have two tools available to determine if you’re in an eligible HPSA area:

Find Shortage Areas by Address

https://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.aspx

Registered HPSA Facilities by State and County

https://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx

CMS has a database of behavioral codes that can be covered under telehealth. Examples of common codes are:

• 90845: Psychoanalysis
• 90791: Psych Diagnostic Evaluation
• 90839 & 90840: Psychotherapy Crisis Intervention
• (POS) Code 02: Telehealth (Created January 2017)

The CMS website has more codes and it’s important to check it regularly since codes change annually. A fee for service schedule is available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup

State Reimbursement: Medicaid

There are some questions you need to consider and ask your payers in each state. Examples include:

• What health services are covered?
• Is cross-state licensing allowed?
• Who are the eligible providers (licensure)?
• Is an in-person session required to establish care?
• Are there location restrictions on the client or provider?
• What are the applicable CPT codes that have been approved?
• What types of fees are reimbursed (transmission, facility, both)?

Ultimately you need to be in direct communication with your payer because every practice’s situation is different. Your payer will be your ultimate source of information on these questions.

Here are some resources to begin to research according to the needs of your practice:

The National Telehealth Policy Resource Center Interactive Map

http://www.cchpca.org/telehealth-medicaid-state-policy

National Medicaid Directory (Interactive Map)

http://medicaiddirectors.org/about/medicaid-directors

American Telemedicine Association State Gaps Analysis

http://www.americantelemed.org/policy-page/state-telemedicine-gaps-reports

Local Telehealth Resource Centers

https://www.telehealthresourcecenter.org

Private Payers: Insurance Carriers

At the time of writing, there are thirty-six states in the USA that have passed telemedicine “parity” laws. This means that private payer insurance companies are required to reimburse telemedicine services the same way they would reimburse in-person services. You can be reimbursed even if the originating site is in the client’s home and the reimbursements are often similar to in-person visits.

A current list of states with telemedicine parity laws is available at http://www.americantelemed.org/policy-page/state-policy-resource-center

As always, you should contact your contracted payers for the final word on telemedicine reimbursement. The following are some questions you should consider:

• Am I aware of the most recent changes to policy?
• Do I need additional informed consent for telehealth?
• Which CPT/HCPCS codes can be completed via telehealth?
• Does the reimbursement match that of an in-person session?
• Is my license type eligible for reimbursement via telehealth?
• Are there any restrictions on the location of the client or provider?
• Is there any additional documentation that I need to collect or provide for reimbursement eligibility?

Always make sure to verify that telemedicine is covered under a specific client’s insurance plan. Even if telemedicine is covered by a certain insurance company that doesn’t mean a patient has coverage for this service under their individual plan.

For tips about verifying coverage, visit: http://www.americantelemed.org/policy-page/state-policy-resource-center

Out of Pocket: Charging the Client

The easiest way to be reimbursed for telehealth services is by billing clients out-of-pocket. You can also choose to charge a client your session fee out-of-pocket and then ask your client to obtain reimbursement from their insurance provider independently.

Many mental health providers ask us what they should charge for an out of pocket session. At minimum, you should charge the same amount you would for an in-person session. Telemedicine sessions provide the same level of care as an in-person session. The only thing that is different is the mode of delivery.

For the added level of convenience that telemedicine provides, some providers elect to charge a convenience fee (often $10-25). These convenience fees are optional and not reimbursable via insurance companies.

Additional Resources and Next Steps

This article should give you a basic level of knowledge to prepare your practice to implement telemedicine into your services.

We also have a one-hour webinar, titled Telemedicine Reimbursement: Understanding Your Reimbursement Options, available here: https://register.gotowebinar.com/recording/1615542510432254979

If you have more questions about telemedicine reimbursement or would like to learn more about getting started with Tele-Counseling, our secure video counseling platform, contact us today.