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Medicaid Telehealth Reimbursement: Ask Permission Or Beg Forgiveness

Expanding consumer demand for telehealth services is driving telehealth reimbursement policy reform. For that reason, telehealth clinicians wanting to provide and bill for services delivered to Medicaid recipients should do their due diligence. That means being cautious not to use nationally published policy guides as the sole source of truth for determining what is covered. Providers billing for services without making sure they are using up-to-date guidelines run the risk of having their claims denied or recouped on retrospective review.

Publications such as the American Telemedicine Association Policy Resource Center State Telemedicine Gap Analysis Report and the Center for Connected Health Policy annual survey and analysis of state telehealth laws and reimbursement policies report are widely used to determine what services will be reimbursed. Both provide a good overview.

Understanding the dynamic nature of Medicaid reimbursement starts with governance. Three governing bodies influence reimbursement for clinical services delivered to Medicaid members using telehealth: state statute, state medical boards’ rules, and Centers for Medicare and Medicaid Services (CMS) Medicaid policies or variations in the CMS policies as amended by individual states. When interpreting policies from each, it is important to consider the hierarchy and impact that conflicting rules have in shaping reimbursement. For example, a state specific Medicaid policy may allow reimbursement to providers for delivering on-demand clinical services to new patients in their homes, while state medical board licensure rules require providers have an established relationship with a patient before telehealth is allowed.

But paying attention to hierarchy and conflicting language aren’t enough. We also need to consider the rate and frequency with which each governing body is introducing policy and rule changes.  For example, reported “the number of bills in Congress could open the floodgates for telemedicine reimbursement and adoption. In the 113th Congress alone, 57 bills were introduced to change current policies."

In addition, when referring to policy updates, be aware of the way some publications categorize telehealth elements as "allowed." While there are many instances when the report list of what is allowed matches with policy and rules, there are some instances in which the report will categorize something as "allowed" when there is no specific reference to it in policy. Providers subscribing to the “beg forgiveness” school -- that is, assuming something is allowed unless there is specific language to the contrary, run the risk of having claims rejected initially.

To maximize reimbursement for clinical services using telehealth, providers should rely not only on national policy update reports, but also on some or all of the additional due diligence steps:

  • Ensure both Center for Connected Health Policy and American Telemedicine Association reports list the services you want to provide as "allowed."
  • Trace footnote links from both reports back to source documents to make sure there is no newer policy or any rule updates.
  • Cross-reference footnotes with other current sources. For example, if a state parity statute is used as a source, it should be cross-checked against any state medical board rules, or state-specific Medicaid policies and and/or provider and billing manuals.  
  • Coordinate with payers to make sure everyone is on the same "effective date" page. Medicaid regulators may give payers time between approval date and effective date to configure their systems to pay.

For the next few years, the telehealth policy reform curve will parallel behind industry expansion. Issues related to risk aversion, billing integrity and quality will begin to take a larger role in measuring telehealth success.  As industry leaders, we must continue to support efforts that reduce policy and payment ambiguity, and increase providers' comfort, knowing their delivery of clinical care using telehealth will be reimbursed

About the Author

Don Graf's picture

Don Graf is a nationally recognized expert on telehealth. He has served on the American Medical Association Telehealth Coding Task Force and, the National Quality Forum Committee to develop a telehealth quality framework and has received national recognition for telehealth innovation from Medicaid Health Plans of America Best Practice Compendium. Don is an Arizona State University graduate and a Flinn Brown Fellow, and has passionately supported and developed telehealth expansion in Arizona and on the national stage for over 20 years. He is a member of the Arizona Telemedicine Council, serves on the board of the New Mexico Telehealth Alliance and was most recently the National Telehealth Director for United Healthcare.

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