We help answer questions all time about reimbursement for telemedicine and teledermatology visits. This post will hopefully answer your most basic questions and shed a little more light on the topic. I will focus on asynchronous telemedicine because that is the most prevalent model in dermatology and the one we support. As a hint, all our current customers offer teledermatology as an out-of-pocket service. Always feel free to reach out to us directly if you have specific questions at firstname.lastname@example.org.
Live-Interactive versus Asynchronous/Store-and-Forward
When talking about teledermatology reimbursement you first have to understand the different types of telemedicine. Live-Interactive telemedicine is what most people think of when they think of telemedicine. Basically, it is a live video conversation usually between a patient and a provider. Think FaceTime or Skype--but secure and HIPAA compliant. In contrast, Asynchronous telemedicine, also called Store-and-Forward telemedicine, is not live and works similar to email or text messaging. The patient or patient representative sends information to a provider who can review and respond at a later time. The information could be a combination of a patient questionnaire, photos, or recorded video. There is no live-interaction so this telemedicine model doesn’t depend on both the provider’s and patient’s being present at the same time.
Our platform at MyDerm Portal is an asynchronous platform so patients can start a visit anytime. A dermatologist can also respond when it is most convenient for them so it does not disrupt their existing clinic schedule.
Originating Site & Distant Site
The originating site is simply where the patient or beneficiary is at the time of the telemedicine visit. The distant site is the location of the provider consulting on the telemedicine visit.
We’ll start with the most straightforward payers. For a more detailed overview of the latest telemedicine laws and reimbursement, the Center for Connected Health Policy is a great resource.
Medicare primarily covers Live-Interactive telemedicine visits. The exceptions are with two pilot programs in Hawaii and Alaska testing asynchronous telemedicine visits). For reimbursement, Medicare has requirements for both the Originating and Distant sites. The originating site, where the patient is, must be at a qualified healthcare facility (i.e. another provider office, hospital, skilled nursing facility, etc.). The distant site provider must be in a site qualified to receive Medicare reimbursement. Finally, there is a geographic requirement for the originating site in order to receive reimbursement. The patient must be in either at a Health Professional Shortage Area (HPSA) or outside of a Metropolitan Statistical Area (MSA). You can search for qualified geographic areas here. Additional details regarding Medicare telemedicine reimbursement can be found here at this link.
Because Medicaid is a state-administered program, telemedicine reimbursement varies state to state. Similar to Medicare, the reimbursement is, by in large, limited to Live-interactive telemedicine visits. Currently, 46 states reimburse for some form of video visits. Each state has their own requirement regarding Originating and Distant sites. However, they generally follow similar types of requirements as Medicare. A total of 9 states reimburse for some type of store-and-forward visits. Some states specifically state what types of telemedicine are reimbursed (i.e. teledermatology, telepsychiatry, etc.). Each of the 9 states reimbursing for store-and-forward require that the patient be at a qualified originating site--the patient’s home is not a qualified originating site.
The short answer is that it depends on the payer and the specific plan. Our experience is that, currently, only a handful of payers reimburse for asynchronous telemedicine visits. To see if a payer reimburses for asynchronous visits, check their latest policies. Here’s an example from BCBS of North Carolina.
Now the more complicated answer! 29 states have passed telemedicine parity laws which mandate that insurers cover telemedicine visits to the same extent that they cover in-person visits. In addition, many of these mandates prohibit the requirement that the patient be at a qualified medical facility--opening up the opportunity to do telemedicine visits with patients in their home. However, in these mandates, telemedicine is sometimes defined as live-interactive, thus, the exception for asynchronous. Further, some of these states have also enacted payment parity which requires them to not only cover telemedicine but to reimburse at the same level as in-person visits. You can read more about this here. This is a space where we’re seeing rapid change and in the next 1-2 years, we see asynchronous visits being covered to the same extent that video visits will be covered.
How you bill for telemedicine will depend on who the payer is. With Medicare, you would use the appropriate visit code along with a modifier indicating the telemedicine modality (GT = Live Interactive, GQ = Asynchronous). With Medicaid and private payers, it is either the normal visit code with or without the descriptive modality modifier (GT/GQ) or 3) or the telemedicine specific CPT code 99444 with or without the modality modifier.