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Commercial Payors and Medicaid Telehealth Billing

The Centers for Medicare and Medicaid Services (“CMS”) and the Department of Health and Human Services (“HHS”) have enacted several measures to make it easier for Medicare beneficiaries to obtain telehealth services during the public health emergency caused by the coronavirus and the disease caused by it, COVID-19. Specifically, CMS and HHS have issued Section 1135 Waivers for Telehealth Services and other guidance to allow providers to treat Medicare beneficiaries using telehealth.

Many state Medicaid programs and commercial payors have likewise made changes to expand the telehealth services offered to their beneficiaries and increase access to care. This alert focuses on recent changes to billing and reimbursement for telehealth services by commercial payors and Medicaid programs.

Medicaid

States have the option to determine what types of telemedicine to cover under Medicaid. Therefore, providers should check with counsel or their state Medicaid program regarding telehealth waivers and billing compliance. By way of example, below is a summary of how Medicaid services have been expanded in North Carolina, South Carolina and Georgia below to illustrate the changes that many state Medicaid programs are making due to the current public health emergency.

North Carolina

The North Carolina Medicaid program has announced several policy changes around the use of telemedicine in response to COVID-19. The North Carolina Medicaid Telemedicine and Telepsychiatry Clinical Coverage Policies were changed to include the following:

  • Payment parity for approved services, allowing providers to receive the same reimbursement for a service regardless of whether it is provided in-office or via an approved technology platform;
  • Expanding eligible telehealth technologies to include any HIPAA-compliant, secure technology with audio and video capabilities including, but not limited to, smart phones, tablets, and computers;
  • Expanding the list of eligible originating sites;
  • Expanding the types of providers that can provide telehealth to include clinical pharmacists, licensed clinical mental health counselors, licensed marriage and family therapists, licensed clinical addition specialists and licensed psychological associates; and
  • Eliminating the need for some prior authorizations and referrals.

These changes were issued on March 20, 2020 and are retroactive to March 10, 2020 and will remain in effect until the North Carolina State of Emergency is declared over or when the policies are rescinded.

Additional North Carolina Medicaid telehealth details can be found here.

South Carolina

The South Carolina Department of Health and Human Services (SCDHHS) announced temporary modifications to policies related to telehealth coverage for Evaluation and Management (E/M) services. SCDHHS indicated that physicians, nurse practitioners or physician assistants can provide E/M services including CPT codes 99202-99204 and 99212-99214 regardless of the Medicaid member’s location. Specific policy changes and waivers include:

  • Requirements related to the referring site are waived and services may be provided without regard to the member’s location.
  • Requirements that a certified or licensed professional be present at the referring site are waived.
  • The audio and video components of the interaction must include sufficient quality for the provider to effectively deliver the care being administered, but any specific technology requirements are waived.
  • Services billed pursuant to this benefit expansion should be billed with a GT Modifier.

These waivers do not apply to telehealth delivered by Federally Qualified Health Centers or Rural Health Clinics, however, SCDHHS indicated that additional guidance for these providers will be issued soon.

These changes are effective for dates of service on or after March 23, 2020 and SCDHHS will begin accepting claims for these policy changes beginning April 1, 2020. The policy changes will remain in effect for the remainder of the public health emergency, unless SCDHHS determines they should sunset at an earlier date.

Georgia

The Georgia Department of Community Health (DHC) provided waivers of certain policies to support the use of telehealth during the COVID-19 public health emergency. The DHC waivers and policy changes include:

  • Waiving the telehealth services originating site limitations; and
  • Allowing telehealth services to be provided via telephone communication, use of webcam or other audio and video technology, and video cell phone communication.
  • Community based waiver providers and home health providers may perform initial and annual assessments, and level of care determinations via telehealth in lieu of face to face visits. Case management services, nurse supervisory visits and assessments for home care admissions may also be provided via telehealth.

Providers must make a good faith effort to ensure that communications are secure and HIPAA requirements are met. In addition, all telehealth services must be medically necessary, and providers must comply with the provisions outlined in the Telehealth Manual. The patient must initiate the service and provide consent to be treated virtually, and the consent must be documented in the medical record.

Billed codes should be identified as telehealth services by utilizing a telehealth Place of Service (POS) code or a telehealth modifier (GT modifier).

Private Payors

Each commercial payor has different requirements for telehealth billing and compliance during the current public health emergency. Generally, most commercial payors are waiving beneficiary costs for COVID-19 testing and visits related to COVID-19 testing. While we have included a summary of a few commercial payors’ telehealth policies below, we would encourage you to consult with counsel if you have any additional questions.

Aetna
Aetna is encouraging its members to use telemedicine by waiving costs for all telemedicine visits through all network providers using telephone care, live video conferencing, Teladoc through the AetnaHealth app, or other apps or services provided by the patient’s plan. These costs will be waived through June 4, 2020. Please note, self-insured plan sponsors will be able to opt out of this program at their discretion).

Anthem Health (Includes Blue Cross Blue Shield of Georgia)
Anthem is offering the following options to connect with a provider and have a virtual visit:

  • Sydney Care, a mobile app assisting members with checking their risk for COVID-19 and setting up a telehealth visit;
  • LiveHealth Online, a live video app for mobile devices to enable all members to conduct a telehealth visit.

All Anthem plans will cover testing for COIVD-19 and an associated visit a no cost to the beneficiary, and a virtual visit with a primary care doctor using Sydney Care or LiveHealth online video through June 14, 2020 at no cost to the beneficiary (this applies to Anthem Fully Insured, Individual, Medicare Advantage and Medicaid, where permitted). Anthem will also cover a virtual care visit text session at no cost between March and June 14, 2020; additional text sessions will cost $19 each.

Blue Cross Blue Shield (BCBS)
All 36 independently owned BCBS companies and the BCBS Federal Employee Program (FEP) are expanding coverage for telehealth services for the next 90 days. Expanded coverage includes waiving cost sharing for telehealth services for fully-insured members for in-network telehealth providers. In addition, the full cost of medically necessary diagnostic tests related to COVID-19 will be covered. BCBS is also waiving prior authorizations for diagnostic tests and covered services if diagnosed with COVID-19. BCBS is also expanding access to nurse and provider hotlines.

Blue Cross Blue Shield North Carolina (BCBSNC) encourages people to seek virtual care whenever possible. BCBSNC will:

  • Encourage virtual visits including appointments with primary care providers, specialists, behavioral health providers, and any North Carolina licensed providers who can provide services via secure video or telephone;
  • Waive cost sharing for virtual visits done by video or phone to screen for COIVD-19;
  • Waive early medical refill limits to ensure members have an adequate supply on hand; and
  • Waive preapproval testing for COVID-19.

Blue Cross Blue Shield South Carolina (BCBS SC) has three device application options for video or virtual visits: Blue Care OnDemand, Doctors Care Anywhere, and SC Department of Health and Environmental Control. There will be no cost for members for Blue Care OnDemand, for a virtual triage visit with the Department of Health and Environmental Control, or for Doctors Care Anywhere COVID-19 triage and testing.

United Health Care (UHC)
United Healthcare is expanding access to care for its members for its fully-insured Commercial, Medicare Advantage and Medicaid plans, including, through May 31, 2020:

  • Waiving member cost-sharing for the testing and treatment of COVID-19;
  • Waiving cost-sharing for in-network non-COVID-19 telehealth visits for Medicare Advantage, Medicaid and fully-insured individual and group market health plans; and
  • Working with preferred telehealth partners including Teledoc, American Well, Doctor On Demand and other partners. Patients should sign in to their health plan account to find their preferred telehealth app.

For all UHC Medicaid plans, any originating site requirements that may apply under United Behavioral Health reimbursement policies are waived so that telehealth services provided via a real-time audio and video communication system can be billed for members at home or another location. In addition, for all UHC Medicare Advantage and Medicare Part B plans, including dual eligible special needs plans, any originating site requirements that may apply under Original Medicare are waived. UHC will reimburse telehealth services which use standard CPT codes and Place of Service 02 for both video-enabled virtual visits and telephonic sessions to indicate the visit was conducted remotely.

Conclusion

We caution providers to pay close attention to policies from commercial payors and Medicaid programs that require secure communications tools in order to conduct telehealth visits. The Office for Civil Rights (OCR) at DHHS has issued an alert that it will not impose penalties for noncompliance with the regulatory requirements under the HIPAA rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. However, while it is clear that many two-way audio and video applications are covered under this waiver, we caution providers to closely examine each payor’s policies regarding audio-only applications. The provider will be responsible for ensuring that the telehealth services provided are compliant with the secure communications requirements from OCR, as well as each payor’s security policies.

There is no question that the COVID-19 public health emergency has created increased demand for telehealth services. As it continues, both state Medicaid programs and commercial payors may make further adjustments to improve access to care and expand reimbursement for telehealth services.