Health plans may limit patients’ in-network options
The COVID-19 pandemic has been devastating across all areas of health and business. Physician practices, for example, on average are reporting a 55% decrease in revenue and a 60% decrease in patient volume, according to the results of a Medical Group Management Association survey. Nearly all surveyed medical groups (97%) report a negative financial impact from COVID-19.
To compensate for a significant loss in patient volume, 48% of physicians are delivering care through telemedicine, according to survey results from staffing firm Merritt Hawkins. Yet many physicians are frustrated with the administrative bureaucracy of this new form of care delivery. Nearlyone-quarter
(23%) of primary care physicians surveyed in early April about COVID-19-related issues report that payment and policy issues concerning telemedicine are obstacles to adoption.
This finding is no surprise considering telemedicine reimbursement is a notoriously complex topic. Policies tend to vary between states, payers, procedure codes and other factors; a variety of myths and misperceptions can complicate virtual health strategy even more. That is one reason clarity is so important when it comes to telemedicine reimbursement – not just because it impacts physician paychecks, but because it can shape the future of virtual health adoption.
A confusing question that puzzles both patients and practices and can even stymie virtual care programs often concerns “steering” – defined as when a payer announces that a virtual visit will only be covered if the patient and clinician use a specific telemedicine vendor. Some physicians run into this so often that it halts their plans to offer telemedicine services. Do insurance plans really have the right to make this decision for their members and network physicians?
The answer is… It depends.
Apps Can Be “In-Network” Too
A payer’s power to restrict telemedicine vendor options does exist – in some cases. This depends largely on whether it is the patient or the physician. The type of service can also be relevant.
If it is the patient’s health plan that offers a type of telemedicine coverage, it often means that the plan will pay for access to a certain product, such as a direct-to-consumer (DTC) app. If the patient wants to pay the negotiated in-network rate offered by the plan, there is not much choice. The patient needs to use the in-network vendor – not just any DTC app. While it may annoy the patient, it does not qualify as steering.
Practices can expect more patients either using or expressing interest in DTC apps and telemedicine in the COVID-19 era. A survey of 2,000 Americans conducted in mid-March, still early in the country’s COVID-19 outbreak, found significant enthusiasm around telemedicine. Although 45% of Americans surveyed said they did not know if their insurance covered telemedicine services or not, nearly 97% said they would at least consider such an appointment. Moreover, of those surveyed who had completed a telemedicine appointment, 60% said they have had more than one already.
Consumer research firm J.D. Power also found that satisfaction with telemedicine services was high before COVID-19: The overall customer satisfaction score for telemedicine services was 851 out of 1,000 in 2019, and was 900 or higher among 46% of telemedicine users. To put it in perspective, this consumer experience rates higher than their experience with their health plan, which averages 713, and on-par pharmacists who score between 884 and 940 points, depending on the number of topics covered. J.D. Power also found nearly two-thirds of telemedicine patients used the service based on a positive recommendation from a friend, family member or colleague.
After this positive experience, the patient may then tell their primary care physician that they have received care from that telemedicine app covered by their health plan. The physician, however, has no record of what was discovered or treated during those visits, which hinders their ability to provide whole-person care. At the same time, the patient tells the physician they liked the convenience of talking to a doctor without even leaving the house. They would like to have that option with their physician, but are uncertain if their health plan will pay for it. The physician, however, is entitled to choose the best telemedicine vendor for their practice and is not required to use the health plan’s in-network vendor.
The Choice is Yours
The practice manager should first study the parity laws and virtual care regulations in the state, which vary widely. With the onset of the COVID-19 outbreak, telemedicine coverage policies are rapidly changing. The Center for Connected Health Policy offers a continually updated state-by-state breakdown of COVID-19-related telemedicine actions, including those states waiving in-state licensing requirements.
After conducting research, the practice manager should contact the patient’s health plan and report that their physicians will be offering virtual services to patients. The plan representative may suggest that the practice “must use” Vendor X if they want those claims paid. That is steering and it is not legal.
The practice has the right to use any telemedicine platform or vendor that enables it to provide clinically responsible, evidence-based care. The vendor in question is irrelevant as long as physicians that bill for those services use the correct codes.
While experienced billing departments and practice management groups are becoming aware of this policy, physicians new to telemedicine sometimes do not realize their rights. The payer needs to be reminded that telemedicine is not just a modern convenience, but it can advance patient outcomes and they, too, are benefiting from virtual care delivery, especially in terms of cost savings. For example, an analysis of acute, non-urgent medical claims conducted by a subsidiary of Anthem found telemedicine saved 6% per care episode, mostly due to averting an emergency department visit.
Physicians are stuck between a rock and hard place: faced with significant financial losses and care demand from patients who are wary of visiting a medical facility during this public health emergency. Rest assured, telemedicine platforms that the physician prefers to use – not the payer – are available to deliver the virtual care that is reimbursable, reduces the risk of virus exposure and improves outcomes.
About the author:
Joel E. Barthelemy is founder and CEO of GlobalMed, a virtual health company with over 25 million telehealth consults delivered in 60 countries and specializing in both federal and commercial spaces.