Private Payer Reimbursement Information Directory
The lack of private payer reimbursement has been identified as one of the principle barriers restricting the acceptance and growth of telemedicine. This perceived barrier appeared to be based on the assumption that private payers do not pay for telemedicine and will resist paying if asked. It was further assumed that private payers followed the lead of Medicaid and Medicare reimbursement practices.
Finding the Solution
In order to prove or disprove the above assumptions, a survey of health delivery organizations offering billable telemedicine services was undertaken to determine if any receive private payer reimbursement, and if so, what policies and procedures they use when submitting claims. In addition, the actions that led to private payer acceptance of such practices and the top five private payers providing payments were identified.
The Survey Process
An initial survey was sent to the approximately 2,000 members of the American Telemedicine Association (ATA). The initial response was poor and determined that the audience was too general. Too better focus the survey, ATA and AMD Global Telemedicine jointly developed a list of 141 active telemedicine programs in the United States. They further defined 72 of these programs as offering potentially billable services. A direct phone survey of these programs was conducted.
The basic assumptions proved false. It was found that more than half of the programs (38) delivering billable services are currently receiving reimbursement from private payers.* Payers are currently reimbursing in at least 25 states. It was also determined that in many cases private payers are not following the lead of Medicaid/Medicare, but are following the lead of Blue Cross/Blue Shield. There are currently 21 states in which Blue Cross/Blue Shield reimburses, where as Medicaid reimburses in only 18 states.
- 3 telemedicine programs receive reimbursement for store and forward
- 7 telemedicine programs receive reimbursement for facility fees
- Over 100 private payers currently reimburse for telemedicine services (this is only a partial list)*
*Of the 41 active telemedicine programs identified, 72 provide billable services, of which 38 receive private payer reimbursement. In total, 53% of telemedicine programs offering billable services receive private payer reimbursement.
* Since many telemedicine providers receiving private payer reimbursement treat the billing of telemedicine services as usual and customary, many do not use modifiers or specialized CPT codes for tracking purposes. Because of this, it is impossible to accurately
Many telemedicine programs have been successful in obtaining private payer reimbursement by taking the following approach:
- Treating telemedicine services as usual and customary medical practices. Actions to try to identify telemedicine consultation as different or requiring “special” coding generally proved counter-productive and of limited value.
- Sending letters to their private payers to include:
- The intent to provide such services, using telemedicine as the normal course of business.
- Notification of future claim submittals
- Encouraging questions and comments from the private payer.
In most instances, private payers either did not issue a response or responded with no requests for special coding. Customary billing procedures were adhered to and the claims were processed and paid.