Telemedicine Reimbursement and Regulation: an Overview for Providers

by Snell & Wilmer

Snell & Wilmer

The advent of telemedicine supplies a unique and convenient gateway for patients and providers to connect. The benefits of telemedicine range from increased access to care for patients, to increased efficiency and lower overhead costs for providers. However, as is common with new models of health care delivery, navigating the regulatory landscape can be a challenge.

As with regulation of almost any health care delivery model, there will be aspects of compliance that involve federal regulation, state regulation, payor specific regulation, and provider specific regulation. In telemedicine, this regulatory scheme is no different.

Providers may wish to consider what regulations are applicable to their telemedicine practice by tracking enrolled patients by payor type. This may help providers assure that they are not only in compliance with applicable contractual or regulatory schemes, but could also assure that they receive reimbursement for provided telemedicine services. One way to do this is to have patients designate which payor type they will be using for their healthcare coverage on a telemedicine specific patient acknowledgement form when they sign up for telemedicine services.

Although there is not comprehensive federal regulation specific to the topic of telemedicine, the big federal player is always the regulatory body for Medicare – the Centers for Medicare and Medicaid Services (“CMS”). Medicare only reimburses telemedicine if it relates to certain types of care, provider types, locations and technology. It is advisable to consult the Medicare reimbursement guidelines for more information on what services will be reimbursed by Medicare. Even for telemedicine services that are not reimbursed by Medicare, it is possible to provide those services to a Medicare beneficiary. However, providers should have Medicare patients sign an Advanced Beneficiary Notice of Nonpayment before providing the services so the patient understands that they may be required to pay out of pocket for certain non-covered telemedicine services.

Medicaid rules on telemedicine vary from state to state. Some states provide a wider scope of reimbursement for telemedicine than Medicare, while others may have limitations similar to those of the Medicare program, such as requirements for the site location of telemedicine services (in office v. at home) or the geographic area where telemedicine takes place (urban v. rural). State specific Medicaid guidance is generally available on each state’s Medicaid website to help providers navigate the Medicaid reimbursement landscape for telemedicine.

Like Medicaid, commercial payors will have their own requirements for telemedicine reimbursement that may vary from state to state or region to region. For example, in Colorado, commercial payors are required to provide telemedicine reimbursement in the same way they provide reimbursement for any other provider visit. The first place to look for commercial payor telemedicine requirements will be the provider’s individual or practice payor contract. This contract should have terms relating to telemedicine reimbursement. From there, a provider may wish to review state legislation to see if there are any state mandated rules regarding telemedicine and commercial payors, like in Colorado.

Once a provider has reviewed the big-picture reimbursement landscape with regard to specific payors, it is important to also verify that the practice/provider is in compliance with other state rules regarding telemedicine, particularly, those involving the regulation of certain providers. For example, some states may regulate whether providers can prescribe via telemedicine, or if there are certain provider types like psychologists and nurse practitioners that can engage in telemedicine in that state. States may also have specific licensing and cross-state practice rules that relate to telemedicine. Provider specific regulations can generally be found in the medical practice acts of each state and the equivalent acts for each other profession, such as nurses, physician assistants or psychologists.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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