Private Payer Telehealth Reimbursement in the United States

Abstract

Background: Significant information is available about government-reimbursed telehealth services such as Medicare and Medicaid across the United States. Although currently 20 states mandate reimbursement for telehealth services and some private insurers have voluntarily covered those services in other states, relatively little is known about telehealth provider experiences with reimbursement from private insurance payers. Materials and Methods: To investigate this, the American Telemedicine Association's (ATA's) Telemental Health Special Interest Group (SIG), the Policy Group, and the Business and Finance SIG, with the help of ATA staff, conducted a national private payer reimbursement online survey in 2012 using Survey Monkey™ (Palo Alto, CA) (www.surveymonkey.com/). Results: Survey responses were received from respondents in 46 of the 50 states. The survey found that telehealth services are being reimbursed by private payers but that progress in reimbursement has been relatively slow compared with earlier surveys. Conclusions: Key findings from this study were that government payers as well as several major private payers are highly influential in payment policies for telehealth private payers, that private payers have administrative rules regarding telehealth reimbursement that are barriers to services and reimbursement, and that some providers would benefit from being better informed about billing and coding for telehealth services and how to advocate for telehealth services reimbursement.

Introduction

Reimbursement for telehealth or telemedicine services by private insurance companies has been repeatedly identified as critical to the development and practice of those services.¹ Increasingly, state governments are mandating that private insurance companies reimburse providers of telehealth services if the services are covered for in-person care. At this time, 20 U.S. states and the District of Columbia have such mandates, with another 13 states having proposed similar legislation.² Some private insurance companies in other states have increasingly voluntarily reimbursed for telehealth services.^3,4 Recent experience that telehealth service providers have had with telehealth reimbursement by private payers in those states or others has not been studied. The information that is available is primarily anecdotal.

Although several studies of private payer payment for telemedicine or telehealth services have been conducted in the past,^1,3,5
–7 there has been no recent major study. There is relatively little information other than anecdotal accounts about current experiences that telehealth service providers have with obtaining reimbursement for telehealth services. The most comprehensive study conducted in 2005 found that 58% of representatives of the 64 responding organizations surveyed indicated receiving private reimbursement for telemedicine services.⁵ The authors also found that a large majority (81%) of the respondents experienced no differences between reimbursements for telemedicine services compared with in-person services.

The purpose of this study was to assess the current status of telehealth reimbursement by private payers and to what extent there has been progress in private payer reimbursement for telehealth services. In February and March 2012, the American Telemedicine Association's (ATA's) Telemental Health and Business and Finance Special Interest Groups (SIGs) conducted a collaborative private payer reimbursement survey of ATA members through Survey Monkey™ (Palo Alto, CA) (www.surveymonkey.com/), to determine the current state of private payer reimbursement for telemedicine services in the United States. Although historically the same exercise has been conducted to determine Medicaid and private payer reimbursement for telemedicine, the methods used in this survey differed. Rather than surveying representatives of organizations providing telehealth services, this report surveyed all individuals who were members of the ATA as well as a large pool of nonmembers of the Association. The intent of this survey was also to identify as many people in as many states as possible who were interested in private payer telemedicine reimbursement, gather information about current private payer reimbursement experiences, and solicit participation in future work on telemedicine reimbursement in the identified states.

Materials and Methods

The survey was sent by e-mail to approximately 13,000 potential participants with a link to SurveyMonkey. The survey consisted of 22 questions about where respondents lived, where they practiced telehealth, their role in telehealth practice, their experiences in billing and receiving payment from private payers, and what reimbursement topics about which they wanted to know more. Six hundred forty persons started the survey, with approximately 143 participants completing the survey. There was no opt-out ability for any question, but branch logic did allow participants to skip questions. The survey was predicated upon the U.S.-based model of reimbursement with private payers and government payers being the predominant coverage groups. Some results were likely affected by some respondents living and/or practicing outside of the United States.

Results

Respondent Roles

As shown in Table 1 the majority of the survey respondents indicated that they were an administrator or a clinician, followed by business manager and “other.”

Table 1.

Survey Respondent Roles

ROLE	%	NUMBER
Administrator	23	210
Clinician	20	178
Business manager	11	96
Clinical coordinator	8	73
Researcher	8	73
Academic	7	67
Industry	7	66
Federal/state agency staff	2	22
Payer	1	5
Other	12	110
Totals	100	900

Many of the 640 respondents indicated having multiple telehealth roles, resulting in 900 responses to the question. The 12% of the respondents identifying their role as “other” included “many” with limited telehealth reimbursement knowledge or experience.

Respondent Residence Locations

Survey responses were received from residents from all states except for Delaware, New Hampshire, North Dakota, and Vermont. The most frequently identified states of residency were, in rank order, California, New York, Pennsylvania, Virginia, Georgia, Texas, Florida, and Arizona. California had the most representation, with 95 participants starting the survey, followed by New York (n=32) and Pennsylvania (n=31). Thirty-nine participants responded “other,” with 11 of those in Canada, 7 in Europe, 7 in Asia, and 5 in South America.

Practice or Work Locations

The frequency that individual states were identified by respondents as where they practiced telehealth was significantly higher than for states identified as locations of residence. This is probably best explained by respondents practicing telehealth in multiple states, not just their state of residence. The top eight states, in rank order, where respondents indicated that they practiced were California (18.4%), New York (11.4%), Pennsylvania (10.6%), Florida (8.9%), Georgia (8.7%), Virginia (8.6 %), Arizona (7.6%), and Texas (7.6%). Eighty-eight (13.7%) respondents indicated a country other than the United States in which they practiced, multiple states without identifying them, or that they were not providing telehealth services.

Because only 178 of the respondents identified themselves as clinicians, it is unclear to what extent the location data by states is accounted for by clinicians providing telehealth services in those states versus how many nonclinicians were providing other services in those states. It is also uncertain how representative these data may indicate the degree to which telehealth services are provided in each state.

Third-Party Payer Billing

Fifty-five percent of the respondents starting the survey indicated that they or their organization did not bill for telemedicine services, with 45% indicating that they or their organization did bill. Because of the 110 respondents who may not be involved in clinical practice or who may not work at an organization that provides clinical care and subsequently bills for telemedicine services and of the number of respondents residing outside of the United States (88 respondents), it is likely that the number of U.S.-based clinicians who bill for services may actually be higher than the survey data suggest.

One of the unanticipated consequences of a broad survey target audience, and the manner in which the survey was written, was that branch logic did not account for persons outside of the United States or those who were not directly involved in clinical practice who completed the survey. Future surveys need to include a branch logic that segregates persons working in a clinical capacity or supporting clinical practice to avoid the issue of unrelated participants.

The major reasons given by survey respondents for not billing for telemedicine services as shown in Table 2, were that (1) major payers do not pay, (2) Medicaid does not pay, (3) the respondent practiced in an urban area, and (4) services were bundled through contracts. (Respondents were able to give multiple reasons for not billing for telemedicine services, resulting in 499 responses to this question by the 325 respondents who answered the question.)

Table 2.

Reasons for Not Billing for Services Delivered via Telemedicine

REASON	%	NUMBER
Practice in urban area	19.3	62
No Medicaid reimbursement	33.0	106
Major payers do not pay	32.4	104
Could not get support from my organization	4.7	15
Too risky for penalties for fraud and abuse	4.7	15
Services are bundled through contracts	17.4	56
Other	43.9	141

Two of the top reasons given by respondents for not billing for telemedicine services related to government payers (i.e., Medicaid and Medicare). Urban area issues for reimbursement are primarily associated with Medicare issues and not as frequently related to private payers, although some private payers do follow the Medicare guidelines. Some telemedicine providers may be exclusively billing Medicaid for services and have limited or no experience in billing private payers for services and/or they are practicing in a state in which Medicaid does not reimburse for those services.

Important to note are the “other” reason and the wide range of explaining comments entered by the respondents. Of note are the responses where Medicare and Medicaid are barriers, lack of understanding of how to bill, and little knowledge of the billing codes. Several programs continue to rely on grant funding to provide support for clinician time in lieu of billing for services. A few responded that the work done was humanitarian or pro bono and not billed.

Only 196 respondents indicated a role in billing for services, with the majority (62%) saying that they played no direct role in billing, with a few respondents (5%) indicating that their role was billing manager and selection of charge levels, they were the billing manager but did not select charges (6%), and 27% indicating an “other” role in billing for telemedicine services. Twenty-six percent of the respondents indicated “other” in defining their role in billing for services. (They indicated their role as supervising or advising on billing, Board of Director member, clinician who bills, business regulatory manager, CEO, project manager, “billing reports to me,” team leader for reimbursement strategy, marketing, evaluator of billing services, trainer, research billing options, business owner and “does it all,” or outside consultant.)

Billing Codes

Significant information was gleaned from the question asking which current procedural terminology (CPT) codes or code ranges were billed for services. One hundred ninety-six respondents answered the question. Again, adjusting for the international health systems that do not use CPT codes, many respondents use the traditional CPT codes for inpatient, outpatient, emergency, and other professional component CPT codes with a range of modifiers indicating telemedicine. There were many different responses to the CPT code question (these included the ranges of 99201–99205, 99211–99215, 99231–99233, G0425–G0427, G0406–G0408, 90801, 90804–90809, 96152–96154, 96150–96151, 90862, G0270, 97802, 97803, 97804, G0108, G0109, 0951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 96116, 99307–99310, G0420–G0421, and Q3014). In addition, several respondents indicated specific codes for state Medicaid, as well as private payers (examples include 90801, 90804–90819, 90821–90822, 90845–90847, 90862, 90887, 96101–96102, 96116–119, 99201–99205, 99211–99215, 99231–99233, 99241–99245, 99251–99255, 99354–99355, 99358–99359, H0002, H0004, H0004HR and HS, H0031, H0034, T1016HO, and T1016HN). The majority of respondents indicated using the Medicare GT modifier to indicate telemedicine, with several examples of other modifiers developed by private payers or state Medicaid agencies (V), and approximately half of the respondents indicating they did not know which modifier was used to indicate telemedicine or if any modifier was used at all. Some participants indicated using the Medicare GQ modifier for store-and-forward.

Payment for Telemedicine Services

Eighty-one percent or 159 of the 196 respondents who responded about whether they were getting reimbursement for telemedicine services indicated that they were getting paid when payers were billed. Nineteen percent indicated that they were not getting paid. Branch logic of the survey required respondents not billing to branch out of the question regarding payment. All 196 respondents who branched to the question regarding getting paid answered affirmatively when asked if they billed for telemedicine services. Assumptions indicated that 19% of the respondents billed but did not get paid for telemedicine services rendered. What is unknown is whether denial of payment was due to the mode of service delivery (telemedicine) or whether or not the service was covered by the payer.

Half (51%) of the respondents did not know if there was a difference in the time it took to get reimbursed for telemedicine services than other services. About 40% believed that it did not take any longer for reimbursement. Only 9% indicated that it took longer to get telemedicine service claims paid.

Medicare and Medicaid

Participants who billed for telemedicine services were asked specifically about Medicare beneficiaries and services delivered via telemedicine. Nearly half (54%) of the 183 respondents provided telemedicine services to Medicare beneficiaries and were receiving payment. Unfortunately, 46% of the respondents indicated that they provided telemedicine services to Medicare beneficiaries for which they were not getting paid. When considering the implications of these findings, the issue of urban areas and CPT codes are two specific findings of this survey that might indicate reasons for providing services to unfunded Medicare beneficiaries.

Similar findings were found in the responses to the question about providing services to Medicaid recipients for which respondents were not paid. Fifty percent of the respondents (n=92) answered that they provided services to Medicaid recipients that were not reimbursed.

Lack of Payment and Services

Forty-eight percent (n=82) of the respondents indicated that they did not provide telemedicine services because of lack of payment, and 55% (n=101) responded that they continued to provide services, even when not reimbursed.

Private Insurance

Two-thirds (67.8%) of the respondents were aware of insurance payers in the state(s) where they worked that paid for telemedicine services. The top insurance companies in the United States identified by respondents paying for telemedicine services were Blue Cross Blue Shield (45%), Aetna (31%), UnitedHealthcare (26%), Cigna (18%), and Humana (9%). About 45% (n=48) of the 106 respondents who answered the question listed “other.” Many of the respondents did not know which private payers paid, listed several of the top 100, stated “all,” or provided very specific health plans located within a small geographic area.

Ironically, respondents most frequently identified the same insurance companies most frequently reimbursing for telemedicine services (e.g., Aetna, Blue Cross Blue Shield, Cigna, Humana, and UnitedHealth) as the insurance companies that do not pay for telemedicine services.

Payment Barriers

Respondents indicated that payers treated telemedicine service claims differently than in-person care claims (see Table 3). The major reasons given for this were (1) differences in billing codes for telehealth versus for in-person services and (2) experiencing greater numbers of denials for telehealth than for in person services.

Table 3.

Reasons Telemedicine Treated Differently Than In-Person Care by Payers

REASON	%	NUMBER
Preauthorization is needed for telemedicine but not for in-person care.	20.1	30
Telemedicine cases are subject to case review before services can be provided (not true for in-person care).	12.1	18
Documentation is different for telehealth than in-person care.	24.8	37
Billing codes are different for telehealth than in-person care.	38.3	57
Must have a preferred provider status for telehealth (not required for in-person care)	16.1	24
Denials are greater for telehealth than for in-person care.	35.6	53

Resource Interests

Although a key purpose of this study was to survey actual experiences providers were having in obtaining reimbursement for telemedicine services, another purpose was to identify individuals willing to serve as resources for their state to help in the future identify major payers that provide and do not provide coverage for telemedicine services. Seventy-eight individuals indicated that they would be willing to help in that capacity.

Reimbursement-Related Topics for Learning

Table 4 lists the frequency of reimbursement topics respondents identified about which they wanted to learn more. The diversity of responses indicates that there is a wide interest of topics by providers or those interested in providing telemedicine services. These would be important to keep in mind for those developing telemedicine reimbursement Webinars, reference tools, and educational events.

Table 4.

Reimbursement-Related Topics for Future Learning

TOPIC	%	NUMBER
Review of Medicare	43.9	180
Review of Medicaid	42.2	173
Review of private payers	48.5	199
How to approach state Medicaid for payment	40.0	164
Billing and coding	47.8	196
Not available	17.3	71
Other	5.9	24

Discussion and Conclusions

The Private Payers Reimbursement for Telemedicine Services survey was successful on several accounts. Nearly all of the U.S. states were represented in the survey, with responses received from all but four U.S. states, and all but those four states were represented in both residency of the telemedicine service provider and the state of practice, indicating that coverage of the survey hit 90% of the target area.

Some providers are unsure about how to bill for telemedicine services, if billing is being done correctly, which private payers pay, and whether or not a billing code modifier is needed or used. Many are using traditional office CPT codes for billing the professional component. True administrative barriers exist when billing private payers for telemedicine services, including preauthorization, using code modifiers, required case review prior to service delivery, required preferred provider status, and other barriers not associated with the same care delivered in person. Some respondents indicated that the denial rate for payment claims is higher for telemedicine services than in-person services.

The majority of telemedicine service providers who do not bill for services would do so if reimbursement were available. Medicare and Medicaid reimbursements continue to be problematic as not only reasons for lack of billing and subsequent reimbursement, but also as precedent-setting policy for private payers. Although half of the respondents indicate that services are provided to Medicare and Medicaid beneficiaries without reimbursement, a greater number of respondents replied that the lack of Medicare and Medicaid coverage limits access to care through telemedicine.

Perhaps the most significant finding from the survey is that comparing the results with earlier studies and acknowledging that progress in reimbursement for telehealth has been made (e.g., increased mandatory and voluntary coverage for private insurance reimbursement), progress remains slow and a barrier for the practice of telehealth. Federal health insurance policies regarding telehealth remain of paramount importance in private payer reimbursement in addition to policies of major private insurers such as Blue Cross Blue Shield. As with prior surveys it was found that billing codes used by payers for telehealth services vary considerably, making it difficult to track telehealth services. Results of this study and the earlier 2007 study⁷ indicate that most providers reported no difference between telehealth services and in-person services.

There are many learning opportunities and several policy implications identified through the responses to the survey:

1. Government payers set precedent for payment policies for some private payers. Elimination of the disparities in federal and state public policy for reimbursement for services delivered via telemedicine would probably encourage more private payers to change their internal policies regarding telemedicine reimbursement.

2. Administrative rules are different for in-person care versus using telemedicine and are viewed as barriers to access to care and reimbursement for services delivered. Universal coverage policies at the state level through the Office of Insurance Commissioner or other legislative/regulatory routes may be necessary to eliminate these barriers.

3. There are significant learning needs for the telemedicine community to better understand the billing and coding processes for telehealth services, how to approach legislators and influence public policy, how to approach and talk with private payers, and how to effect change in secular, specific reimbursement arenas such as certain health professions, certain services, and certain service delivery sites.

This survey has limitations in terms of the basic results that are confounded by the lack of more detailed analysis and distinguishing responses from U.S. and international respondents. Another limitation is that the survey did not include or compare information from the private payer plans with provider perceptions of telehealth reimbursement. In addition, the survey is positioned as very preliminary work to larger reimbursement efforts aimed at the private payer community and points out the need for more comprehensive study.

Footnotes

Acknowledgments

The authors wish to thank Jordana Bernard of the American ATA and members of its Telemental Health SIG (especially Tania Malick, Marlene Maheu, and Thomas Kim) and Business and Finance SIG for providing significant input and support and assistance in conducting and analyzing this survey.

Disclosure Statement

No competing financial interests exist.

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