Telehealth has spread over vast areas of the healthcare industry. The recent pandemic enhanced the use of telemedicine or telehealth which indeed played a crucial part in the industry. Telehealth billing is one among the critical areas of medical billing. It includes various regulations and laws that stand as the vital point during reimbursements.

With the help of technological advantages, healthcare facilities and professionals have the chance to be at the forefront of health care delivery. At the same time, along with the opportunities come the challenges too. When the laws and regulations struggle to handle the speed of innovation, it is critical to consult with a legal services provider with experience and resources to help healthcare professionals grow their business while managing the evolving issues associated with this telehealth billing.

A recent survey report from Foley’s Telemedicine and Digital Health Industry Team showed that it helps clients embrace the emerging issues in telemedicine and digital health by enabling them to provide innovative care for patients in new markets around the world. It was a 50-State Survey of Telehealth Commercial Insurance Laws. As we know, laws and regulations constantly keep on changing. Here are the statutes and regulations for precise legal requirements.

What are the Telehealth Commercial Coverage and Payment Parity Laws in Telehealth billing?

  • At present, there are 43 states and DC which have some sort of telehealth commercial insurance coverage laws along with bills, which are currently under the development in several other states.
  • These laws are often referred to as “telehealth commercial payer statutes” or “telehealth parity laws”. They are especially designed to promote patient access to care with the help of telehealth in a multitude of scenarios- whether the patient is in a rural area without healthcare specialist care, or a in a busy metropolitan city without time to devote three hours to travel to an in-person checkup in a crowded waiting room.
  • There are significant variations across the different states, but two things are related to distinct concepts and have emerged significantly – telehealth coverage and telehealth payment parity.

Telehealth Commercial Coverage laws of Telehealth Billing:

  • Telehealth coverage laws typically require healthcare plans to cover the services provided through telehealth to a patient to the same extent as the plan would have covered if the services were provided through an in-person visit.
  • The laws also do not mandate the healthcare plan to provide its members, an entirely new service line or specialties, along with the scope of services in the enrollee’s member benefit package, which remains unchanged.
  • These laws do not require a healthcare plan to provide identical coverage to any and all patients. The benefits still track the covered services under each individual patient’s healthcare benefit plan.
  • While drafting a telehealth commercial insurance coverage law, there are two important decision points- whether to:
  1. Cover telehealth-based services to the same extent that service is covered when it’s provided in person. (or)
  2. Cover additional virtual care services, such as remote patient monitoring, even if the service is not applicable for the in-person setting.

About Telehealth Payment Parity Laws:

  • A subset of states with telehealth coverage laws also includes language regarding reimbursement rates for telehealth services. These laws are often referred to as telehealth payment parity laws. Telehealth payment parity is entirely different from telehealth coverage.
  • A telehealth payment parity law requires the healthcare plan to pay the network provider for a telehealth service delivered at the same or equivalent reimbursement rate as the health plan pays the healthcare provider when the exact service is delivered in person.
  • Payment parity laws were created in response to healthcare plans paying for telehealth services at only a fraction of the rate the health plan pays for the identical service when delivered in person.
  • This can occur when a state enacts a broad telehealth coverage law, but fails to include any language regarding the reimbursements or payments of telehealth services.

 

At present, 43 States and DC maintain some sort of telehealth commercial payer statute and West Virginia has joined the list in 2020.

Does the State Have a Telehealth Commercial Payer Statute?

  • The State has a law addressing the commercial health plan coverage of the telehealth services.

Does the Law Have a Coverage Provision? Does the state’s law expressly discuss the coverage parity?

  • The law requires commercial insurance companies to cover healthcare services delivered through telehealth. It should be known if the insurance companies would cover the same services if they were provided during an in-person consultation.

Does the Law Have a Reimbursement Provision?

  • Does the state law expressly include the language addressing payments and reimbursement rates for telehealth services?
  • For some states, it means that the commercial insurance companies must pay the healthcare providers for a healthcare service delivered through telehealth at the same reimbursement rate. The insurance companies would pay the same provider for the exact service if it was delivered in-person.
  • For rest of the states, the reimbursement language sets a basement and gives instructions on how the parties must negotiate rates for the telehealth services while telehealth billing.

Does the state impose restrictions on the patient’s originating site?

  • Few states still require the patients to be located in particular clinical settings at the time of the telehealth consultation.

Does the state have cost-shifting protection?

  • The state law prohibits a commercial insurance company from charging a patient a deductible, co-insurance, or co-payment for the telehealth consultation which exceeds what the insurance companies would charge for the same service if it was provided during an in-person consultation.

Provision for Narrow or Exclusive or In-Network Provider Limits:

  • It should be noted whether the state telehealth law has language addressing a health plan that may limit coverage and reimbursement for telehealth services to only those healthcare providers who are within the plan’s narrow telehealth network, exclusive network contracting, or payment provisions for in-network vs. out-of-network providers.

Remote Patient Monitoring (RPM):

  • It’s important to note if the state requires the coverage of Remote Patient Monitoring Services.

 

Variations exist among the laws and every state does not have strong coverage parity. So make sure to read the actual statutory language.

 

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