Telehealth During and After COVID-19

Telehealth has long been discussed as the next new thing in health care, but its actual movement has been slower than many experts expected. The COVID-19 pandemic has changed that equation, with massive increases in accessibility and use because of shifts by payors, both public and commercial, and patient acceptance. Historically, providers did not embrace telehealth services quickly because of lower reimbursement. Furthermore, telehealth requires a potentially costly infrastructure, as well as changes to core revenue cycle processes, to properly identify  insurance, capture charges, submit claims and bill patients. Patients preferred to see their doctors and health care providers in person and were not sure of their insurance coverage and options for telehealth. Beginning in 2019, procedural billing codes (CPT) began to reflect an increase in telehealth and remote-based services. Until just recently, those codes gathered dust in medical coding books. COVID-19, however, has proved a game-changer because insurers have expanded payments for telehealth, which is safer because it allows social distancing. 

Telehealth Defined

Telehealth breaks down into distinct segments: direct to consumer (“B2C”) and via providers/practices (“B2B”). In B2C, providers deliver services directly to patients via electronic means, and the provider may either be a patient’s regular provider or a specialty consult provider by another practice. In the B2B universe, the clients secure either second opinions or even initial results (e.g., “wet reads” on radiology). There are three types of services in these segments (1) two-way communications; (2) telephone only; and (3) online only. Two-way communications, using interactive audio-video creates a virtual visit between a provider and a patient, and those visits mirror traditional evaluation and management (CPTs, 99201-99215), plus telehealth-specific consultations (CPTs, G0425-G0427, etc.).  Telephone only is a brief (5-10 minute) virtual check-in for established patients (CPT, G2012). Finally, there are other online-only services via email or an online patient portal for established patients (CPT, 99241-43 and G2061-63). This article focuses on the B2C segment along all three types, but especially (1) and (2). 

B2C telehealth visits have grown slowly over years. A 2018 Harvard study found that telehealth visits rose from 0.02 visits/1,000 in 2005 to 6.57 visits/1,000 in 2017. Since COVID-19, that volume of visits has exploded as patients have elected not to go to offices. Facilitating this shift, insurers have expanded services/procedures that qualify for telehealth (CPT and HCPCS codes). In addition, they have expanded the array of providers allowed to deliver telehealth services, waived co-pays/cost-sharing (e.g., CMS) and reduced HIPAA burdens for providing services.  Finally, CMS and payors have loosened restrictions (e.g., HIPAA, etc.), allowing use of common platforms, such as Facetime or Skype.

What COVID-19 Has Changed

The demand for social distancing has prompted CMS (Medicare/Medicaid) to expand telehealth, and private insurers have followed. Most, if not all, commercial payers now accept telehealth, including Blue Cross, Aetna, Cigna, and United Healthcare, as well as W/C and PIP—albeit with required preauthorization. Furthermore, previously unforeseen expansion of the use of telehealth with specialty physicians (e.g., orthopedists), as well as a wider array of services—such as PT, OT, and ST—are now clinically viable. Under the new rules, not only private practices (MDs, NPs, PAs, etc.), but also an array of independent clinics (e.g., FQHCs) or facility-based clinics (e.g., hospital and dialysis centers) can provide these services. Furthermore, both originating and distant sites can include both patient homes and physician homes.

Moreover, the leap in public acceptance is evidenced by the explosion of volume. The CDC and state health agencies have pushed telehealth utilization. Modern Healthcare recently reported that “Teladoc Health's remote visits have surged during the COVID-19 pandemic, with the company reporting Tuesday that it is providing more than 20,000 virtual appointments each day ... representing 70% growth year over year. ‘If there was ever a question about whether virtual care could play a leading role in the health care landscape, I think that has been answered,’” said CEO Jason Gorevic. In a recent survey, two-thirds of respondents said that COVID-19 has increased their willingness to try telehealth in the future. One quarter of respondents had previously not considered this an option prior to the public health emergency. Finally, NYU Langone Medical Center went from 20 to 1,300 virtual care clinicians in a few days and has seen up to 6,500 virtual visits in a day. More than 70% of their visits are now virtual.

Provider Concerns

Providers remain anxious about telehealth, even though they appreciate that the imperative to serve patients and maintain social distancing has changed provider attitudes. But major questions need detailed understanding and explanation to both providers and administrative staff. Providers still struggle with understanding which services can be performed remotely. Prior to COVID-19 expansion, allowed services included digital monitoring (e.g., EEG, BP, and health assessments, some in conjunction with devices), physician visits, and a range of mental health services. New services include PT, OT, and speech therapy. 

Billing-related concerns remain extensive. For example, what role time plays in each code set, since some codes require time to authenticate their use; others are not dependent on time. The need for documentation is required to ensure compliance, because telehealth services can be audited retroactively. Details on coding, place of service, modifiers, and other key indicators vary by payer and service. Each carrier has specified different CPT/HCPCS codes; place of service varies from 02 telehealth or 11 office; modifiers include 95 synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system, GT via interactive audio and video telecommunication systems, or GQ via asynchronous telecommunications system. Physicians and administrative staff require detailed education and oversight to ensure compliance.               

Implications for the Future

Telehealth is now here to stay and will likely evolve faster than previously anticipated. Even before COVID-19, telehealth was projected to grow to $130 billion by 2015, with physicians performing these services growing at 20% per year. Nevertheless, we may see some pullback from the flexibility offered by payors during the COVID-19 pandemic. In particular, rural geographies and poorly distributed specialties, such as mental health care, will drive this growth. Moreover, with patients embracing telehealth, it is likely that providers will have no choice but to adapt to patient demands. Success for practices—strategically in their markets and operationally and financially—will depend on strong understanding of the rules and requirements, especially on the revenue side. Appropriate utilization of services may allow time-strapped physicians to accommodate more patients into their schedules and monitor chronic diseases more effectively, thus adding to value-based care requirements as well as increasing effectiveness of patient care and the patient experience. However, careful planning and expert guidance will be required.