Telehealth Payment Revelations

September 17, 2020 
By New England Accounts Receivable Management

During the start of the initial outbreak of Covid 19,  billers were delighted that the Government, and most other insurers, came up with very specific guidelines about billing Telehealth visits.  As usual, confusing at first but once confirmed by CMS, all others seemed to follow.  However, as is always the case with the introduction of any new policy, there were some carriers who wanted their own guidelines. 

The Telehealth policy allowed clinicians to continue treating patients by electronic device methods such as Zoom, Skype and went so far to say that in some hardship cases, telephone visits were acceptable. Visits could be billed with just the same E & M level as if the patient were seen in person by just adding a 95 modifier. 

We all know what a stretch this was for the insurers as personal, face to face, hands on contact with the patient was always the standard for reimbursable patient encounters using and E & M code level. 

As we started to see reimbursements, which were not very timely, due to the carrier’s inability to program their systems as fast as we could submit claims, the problems became evident.  Many Clinicians used the CMS guideline of upcoding their visit one level if 50% or more of the visit time was spent in counseling the patient or their family members.  Once the carrier denied the claim or down coded the visit, the appeals began.  Notes were submitted to the carrier asking for legitimate reimbursement of the visit only to be denied again if the time for counseling was not correctly noted.  Others used an E & M level and added the counseling codes of 90836 or 90838, add on codes to be reported with an E & M code when counseling performed.  These counseling codes were rejected if the provider did not have a Psych profile on the contracts with the carrier.  Message is “provider not eligible to bill this code”.  Those Medicare patients who had a secondary carrier that outsources its Mental Health benefits, had the claims denied by the secondary if the patient did not have “out of network” benefits on their policy. 

So despite the carriers claims that Telehealth was to be paid for their insured, it is not always the case.  The only good news is that co-pays and deductibles have been waived in most cases if all other criteria for the visit was met.

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