Commercial payer patchwork is holding back telehealth’s promise

AMA News Wire

Commercial payer patchwork is holding back telehealth’s promise

Oct 23, 2023

For telehealth and digitally enabled care to live up to the full potential that technology offers, private health plans need, among other things, to expand what Current Procedural Terminology (CPT^®) codes they cover and increase their transparency about coverage and payment, says research from the AMA and Manatt Health.

The AMA Future of Health report (PDF) includes a detailed comparison of digital medicine code coverage across 16 commercial payers, shedding light on which digital medicine codes they pay for, examining how coverage decisions are made and comparing the practices to Medicare payments.

Researchers looked at publicly available coverage policies for 21 digital medicine services that fall across these four categories:

• Remote patient monitoring and self-monitored blood pressure.
• Interprofessional telephone, internet or EHR consultation—called an eConsult.
• Online digital evaluation and management—or an eVisit.
• Remote therapeutic monitoring.

After doing so, they concluded that achieving fair, equitable and transparent coverage and payment of digital medicine services remains a challenge. Starting Dec. 1, Aetna will no longer cover audio-only or asynchronous, text-based visits, according to Healthcare Finance.

For example, if a physician practice that wants to bill for a telehealth eVisit for one of its Blue Cross Blue Shield patients had better check the map first. While Blues plans in Michigan, North Carolina and Texas and will pay for eVisits with CPT codes 99421–99423, their counterparts in the District of Columbia, Maryland, Massachusetts and Virginia will not, says the report. As for the Blues plan in Illinois, “no public information on coverage status or no coverage decision” had been made as of August.

Responding to the report, AMA President Jesse M. Ehrenfeld, MD, MPH, said “the lack of commercial coverage can be a roadblock or bottleneck to affordable access to digital medicine services for more than half the U.S. population who count on private health insurance.

“Barriers to clear and consistent coverage policies must be addressed for the pace of digital health progress in medicine to match the technology’s promising potential,” added Dr. Ehrenfeld.

Supporting telehealth is an essential component of the AMA Recovery Plan for America’s Physicians.

Telehealth is critical to the future of health care, which is why the AMA continues to lead the charge to aggressively expand telehealth policy, research and resources to ensure physician practice sustainability and fair payment.

As the nation’s health care system strives to provide a hybridized care model that includes in-person care and digitally enabled care, the AMA and Manatt Health report outlines these six key themes when it comes to how private insurers are covering digitally-enabled care.

Lack of coverage alignment across commercial payers, Medicare and Medicaid. Commercial payers trailed Medicare in what they cover. Medicare and Medicare Advantage covered all of the 21 digital medicine services researched; private plans did not.

Inconsistent coverage policies within the commercial market. Most commercial payers studied covered remote physiologic monitoring; electronic consults and electronic visit coverage was less consistent.

Inconsistent levels of transparency for coverage policies within the commercial market. Some plans had clinical coverage policies for digital medicine services publicly available. However, many had no public information or the available information was hard to access or was dated, preventing patients and physicians from making informed decisions.

Time lag for determining coverage policies within the commercial market. There was no specific timeline for commercial payers to review and make coverage decisions about digital medicine services, creating uncertainty and complicating planning and investment in digital health programs.

In addition to expanding coverage and increasing transparency, the issue brief outlines how physicians and other stakeholders can scale digitally enabled care models. To do so, it is critical that stakeholders:

• Create new and updated existing digital medicine codes as new technologies, care models and evidence emerge.
• Expand and disseminate the evidence base and best practices for digitally enabled care.
• Promote state policies that require health plans to cover digitally enabled care services when clinically appropriate.
• Encourage more industry engagement around digitally enabled care coverage and payment, which may include clinician, patient and payer education around the value of digital care services and availability of payment.

Through its ongoing leadership, the AMA is working to ensure the health care system can harness the full potential of digitally enabled care to meaningfully improve access, quality, outcomes, affordability and health equity.