3 Steps to Take on Telehealth, Virtual Care

The pandemic led to a surge in telehealth and virtual health use. While those levels have since receded, these care delivery modalities continue to be an appealing option for patients. Your navigation of the complexities can be a tricky though, as those vary by state, provider, payer, and patient.

Here are a few items to keep in mind as you move through this year.

Background: synchronous telehealth, asynchronous, technology-enabled care

These are all care delivery modalities. Synchronous has historically been considered telehealth (or telemedicine) by Medicare. It means real-time audio and visual interaction. For example, you jump on your computer or phone and have a face-to-face interaction with your nurse practitioner or doctor.

Asynchronous interaction, also known as “store and forward,” is when information is shared between providers and/or patients but not in real-time. For example, you send your dermatologist a photo of a concerning skin lesion via your patient portal. Asynchronous interactions can include things like e-visits or virtual visits under Medicare.

Even further, there is technology-enabled care like remote physiological monitoring (RPM) or remote therapeutic monitoring (RTM) where a patient’s physiological or related information is collected and transmitted back to a care team via digital/tech-enabled devices.

With any of these modalities, there are many considerations to keep in mind—coverage, reimbursement, billing, coding, legal and licensing requirements to name a few.

At a high level, coverage and reimbursement hinge on the payer involved.

• Medicare fee-for-service (FFS) has specific requirements for telehealth. For example, telehealth requires an allowable “originating site” and “distant site provider.” The originating site can only be specific locations, like clinics or hospitals, and only in rural areas. Distant sites only included a specific list, like physicians. Further, reimbursement is only available for a certain set of telehealth codes. For asynchronous interactions or technology-enable care, they have their own set of coverage/billing requirements as well.
• Medicare Advantage must cover what Medicare FFS covers, but some Medicare Advantage plans may provide other coverage options.
• Medicaid coverage/payment for any of these modalities is determined on a state-by-state basis.
• Commercial coverage will be plan-specific. Plus, some employers may provide free telehealth/virtual care options.
• Direct to consumer options are available. They would be outside of health insurance coverage and would have pre-set costs per visit or per month, for example.

For licensing and legal requirements, those are based on both state and federal requirements. For example, scope of practice and licensing are dictated by each state which means providers would need to be licensed in the state where their patients are located. States may also have specific telehealth laws that come into play. Federal laws may have additional requirements such as prescribing controlled substances if treating a substance use disorder patient, for example.

Current Public Health Emergency (PHE) Flexibilities

The PHE was in effect during the COVID-19 pandemic. The PHE officially ended on May 11, 2023. During that time, the federal government waived many requirements and granted flexibilities for all types of existing regulatory, compliance and billing requirements, including for telehealth and other types of virtual health. For example, the federal government added hundreds of additional codes on a provisional basis to its list of allowable “telehealth” codes, which means they were reimbursable. States and other payers also provided various flexibilities.

Even though the PHE is over, many of Medicare’s telehealth and virtual health waiver flexibilities have been extended through the end of this year under the Consolidated Appropriations Act of 2023. However, beginning January 1, 2025, these flexibilities revert to pre-PHE requirements (unless Congress passes legislation making them permanent).

Example: Medicare Telehealth Requirements    

What Are We Watching in 2024?

Since these flexibilities expire at the end of the year, we’ll be watching the following to see if the policy landscape changes.

• 2025 Physician Fee Schedule. We are watching for what the Centers for Medicare & Medicaid Services (CMS) will propose under their 2025 physician fee schedule (PFS) rule. Proposed rule is due out in mid-year with the final rule due in late fall. Take a look at CLA’s analysis of this year’s PFS final rule to see how CMS adjusted these tele/virtual codes for this year.
• Congressional Action. We are watching to see if Congress takes action this year on various PHE flexibilities. There is pressure on Congress by stakeholders to act, but it has been difficult to move much of any health care related policies recently. If something were to move, we would expect it to happen in late 2024.  

Three Steps to Take Now

With so many moving parts, it’s important to evaluate your program and see which flexibilities you may be using. Then you’ll need to prepare for any 2025 eventuality. To start, we suggest the following three actions:

1. Understand your current state. Use available resources and toolkits to help you.

• Review HHS’s telehealth website.
• Review the current list of Medicare eligible telehealth codes.
• Find state/federal policy coverage and related requirements
• Read the updated MLN Telehealth Services Fact Sheet (Feb. 2024)
• Find your regional telehealth resource center  
• Grants available. Distance Learning & Telemedicine Grants | Rural Development (usda.gov)

2. Re-assess if any potential changes will impact your digital/telehealth strategy and how you can adjust to keep your efforts aligned with organizational goals.

3. Reach out to CLA if we can assist you with your digital strategic plan or are interested in other aspects of telehealth and virtual health care delivery.