Medicare, Medicaid, and major private insurers provide some coverage for telemedicine, but reimbursement policies vary significantly between payers and states. To get reimbursed, providers must verify a patient's insurance, use eligible telemedicine services and codes, and may need to partner with an approved originating site. While telemedicine offers convenience, navigating reimbursement requires careful review of each payer's unique guidelines.

1. How to Get Reimbursed for
Telemedicine

2. Telemedicine Reimbursement
Medicare
Medicare reimburses for
telemedicine nationwide,
but doesn’t allow
telemedicine from the
patient’s home.
Medicaid
48 state Medicaid
programs cover
telemedicine (CT & RI do
not).
Private
The big 5 (United
Healthcare, Aetna, Cigna,
Humana, BCBS) all cover
telemedicine, but coverage
is policy-dependent.
The 3 Types of Payers

3. Medicare
• Medicare is a national program run CMS to provide government-funded healthcare
for Americans 65 and older (and youger adults with disabilities)
• Medicare lags behind the other payers for telemedicine reimbursement
• Medicare guidelines are still mostly based on traditional model of telemedicine,
where the patient would come into a small, rural health clinic to do an online visit
with a far away specialist
• This is where the terms “originating site” and “distant site” come in
• Legislation is in the works to expand Medicare coverage of telemedicine soon
Main Points

4. Navigating Medicare
• Originating Site – the location of the patient at the time of the telemedicine visit
• Distant site – location of the provider at the time of the telemedicine visit
• Eligible providers – healthcare providers that can get reimbursed for telemedicine under
Medicare
• Facility fee – fee that can be charged by the originating site as payment for “hosting” the
patient for the telemedicine visit
• HPSA– Health Professional Shortage Area
Terms you need to know

5. Navigating Medicare
1. You must be doing live video telemedicine
• Medicare only covers telemedicine via live video
• The only exception is for AK and HI, where store-and-forward is covered as well
• Live video telemedicine means you can see and hear the patient in real-time,
like an in-person visit
• Store-and-forward (also called asynchronous) telemedicine is where you’re
sending medical data or diagnosis remotely and not talking to the patient in real-
time
How to Get Reimbursed

6. Navigating Medicare
2. Patient must be at an eligible Originating Site
• The originating site must meet 2 conditions:
1) It must be in a Health Professional Shortage Area (HPSA)
• To find out if it’s in a HPSA, type address into here
2) It must fall into one of these categories:
• At this time, Medicare does not recognize the patient home as an
originating site
How to Get Reimbursed
• Physicians or
practitioner offices
• Hospitals
• Critical Access
Hospitals (CAH)
• Rural Health Clinics
• Federally Qualified
Health Centers
• Hospital-based or CAH-
based Renal Dialysis
Centers
• Skilled Nursing
Facilities (SNF)
• Community Mental
Health Centers (CMHC)

7. Navigating Medicare
• July 7th, 2015 - House representatives introduced the Medicare
Telehealth Parity Act of 2015
• If passed, the bill will get rid of some of the limitations on what qualifies
as an originating site
When will Medicare recognize the patient home as an eligible site?

8. Navigating Medicare
• Set-up a partnership with an eligible originating site that’s close to your
patients
• Tell patients where to go for the telemedicine visit
• Have a coordinator/telepresenter there who can orient the patient
• Send a letter to CMS and call for a change!
Ok, so how can I do telemedicine through Medicare for now, if the patient
can’t do it from their own home?

9. Navigating Medicare
3.Telemedicine needs to be delivered by an eligible healthcare
provider:
• Physicians
• Nurse practitioners
• Physician assistants
• Nurse-midwives
• Clinical nurse specialists
• Certified registered nurse anesthetists
• Clinical psychologists
• Clinical social workers
• CPs and CSWs
• Registered dietitians or nutrition professionals
How to Get Reimbursed

10. Navigating Medicare
4. The medical procedure needs to
be on the list of covered services
• Here’s the complete list of medical
services eligible for telemedicine
reimbursement
• Check for CMS updates to the list
of covered telehealth services
here
How to Get Reimbursed

11. Navigating Medicare
• Use the appropriate CPT/HCPCS
code
• Add the “GT” modifier to show the
service was delivered via
telemedicine
• If you’re an originating site, use
HCPCS code Q3014 to bill a facility
fee as payment for hosting the visit
How to Bill

12. Navigating Medicare
• Medicare reimburses telemedicine at the same rate as in-person
visits
• Just check the CY Medicare physician fee schedule for the
appropriate CPT/HCPCS code to see rate
• You can also get a 10% bonus for delivering services to a HPSA
• To see if it’s in a HPSA, type address here
Reimbursement Rates

13. Next Payer up…..
MEDICAID

14. Navigating Medicaid
• Originating (Spoke) Site – the location of the patient at the time of the telemedicine visit
• Distant (Hub) site – location of the provider at the time of the telemedicine visit
• Eligible providers – healthcare providers that can get reimbursed for telemedicine under Medicare
• Facility fee – fee that can be charged by the originating site as payment for “hosting” the patient for the
telemedicine visit
• Referring provider – the healthcare provider at the originating or spoke site. This provider is acting as the
host.
• Consulting provider – the healthcare provider at the distant or hub site. This is the provider who’s actually
delivering the medical service.
• Telepresenter– professional at the originating (or spoke) site who helps patient get set-up for the
telemedicine visit.
Terms you need to know

15. Navigating Medicaid
• Since every state has its own Medicaid
program, every Medicaid program
has different rules for telemedicine
• Always read your state Medicaid telemedicine guide
• Go to your Medicaid website
• Search for your provider manual on telemedicine
• For instance, here’s Georgia’s telemedicine manual
• And talk to your state Medicaid department
• You can also get help from your regional telehealth resource center
Main Points

16. Navigating Medicaid
• 48 state Medicaid programs offer some form of coverage for telemedicine
(except CT & RI)
• 24 states cover telehealth under their state employee plans
• 24 states plus DC don’t require a specific patient location as a condition for coverage
• 25 states recognize the home as an originating site
• 82% of U.S. states cover telemedicine state-wide, with no restrictions on distance
between provider and patient
• 15 states plus DC don’t specify type of healthcare provider as condition of payment
• 28 states plus DC don’t require a telepresenter
*based on recent report by the American Telemedicine Association (ATA)
Medicaid Telemedicine Trends

17. Navigating Medicaid
1. Lookup the Medicaid telemedicine reimbursement rules for your state
• The National Telehealth Policy Resource Center has an interactive
map of telehealth policy, state-by-state
• Visit your state Medicaid agency website & read your Medicaid
handbook
• Read this policy analysis from American Telemedicine Association•
How to Get Reimbursed Through Medicaid

18. Navigating Medicaid
2. Know what to research
Here are some of the common restrictions and guidelines that may affect your
telemedicine reimbursement through your state Medicaid program:
How to Get Reimbursed Through Medicaid
• Type of Telemedicine (Live video, store-
and-forward, remote patient monitoring)
• Health Services covered & Applicable CPT
Codes
• Eligible providers (Physicians, NPs, PAs etc)
• Distance or Geographic restrictions (Does
patient need to be located in certain
region, or distance from provider)
• Is a Pre-existing relationship with patient
required?
• Location restrictions on patient or provider
(what defines an eligible originating site?
Eligible distant site?)
• Informed Patient consent (do you need to
get patient’s consent before the visit?)
• Type of fee reimbursed (transmission,
facility, or both)
• GT Modifier (do you to use the GT modifier
when coding?)

19. Navigating Medicaid
3. Record your research and think about how it affects your use case
• Download our Medicaid state policy worksheet here
4. Contact your Medicaid department or Rep with questions
How to Get Reimbursed Through Medicaid

20. Next Payer up…..
Private Payers

21. Navigating Private Payers
Telemedicine Parity Laws
• State telemedicine parity laws require private payers to reimburse for telemedicine
the same way they would for in-person medical services
• 29 States + DC currently have parity laws (9/2015)
• Check if your state is covered here
Things to Know
Map created by the American Telemedicine Association
2015 Source

22. Navigating Private Payers
• The Big Five commercial insurance carriers
cover telemedicine
• BCBS
• Aetna
• Cigna
• United Healthcare,
• Humana
BUT……
• Coverage by private payers is policy-
dependent
• A patient with a BCBS gold policy in North
Carolina might have telemedicine listed as a
covered service for their policy
• A patient in same state with BCBS silver, may
not have it
Things to Know

23. Navigating Private Payers
• So how to you ensure a patient’s private
insurance will reimburse for telemedicine?
• You have to verify before the visit
• Verify insurance coverage for each patient
• ALWAYS record that call with a verification
form
• Use our example verification form
Things to Know

24. Navigating Private Payers
• Like with Medicaid, private payers in your state are influenced
by state policy
• Plus, each private payer has their own telemedicine
guidelines
• The best way to check their telemedicine reimbursement
requirement? Call them and ask questions
Check with your payers

25. Navigating Private Payers
• Pick your top 3-5 private payers and call their eligibility &
verification department
• Ask the right questions:
• Which CPT and HCPCS codes can be completed via telemedicine?
• Do I need to use the GT modifier?
• Do I need prior authorization?
• Are there any restrictions on the location of the patient or provider?
• Does the reimbursement rate match the in-person rate?
• Which providers are eligible (physician, NP, PA)?
• Are there any specific notes that need to be included in the visit documentation?
• Do you have a handout or guide you could send me on your telemedicine guidelines?
Calling your private payers

26. Navigating Private Payers
Billing Trends
• Private payers tend to follow Medicare on billing
• Generally you would use the appropriate E/M CPT code plus the
GT modifier
• But, some payers accept the telemedicine-specific code 99444
• Again, always check coding guidelines with your payers. These
are just trends we’ve seen for context.

27. Our Recommendations
• Consider starting with one payer, or one use case
• For instance, offer telemedicine only to patients with a Medicaid plan
• Or, only offer telemedicine visits to patients with a chronic condition
• Once you figure out the workflow for that payer or use case, grow from there
• Always call your private payers and verify their guidelines
• Connect with your state Medicaid department and your regional telehealth
resource center to verify guidelines and get questions answered
• Always verify a patient’s insurance covers telemedicine using the example
verification form we provided
• Yes, you’ll need to do it for each patient, but only for the first visit!

28. If all else fails…
• Patients love the convenience of telemedicine
• Many of our clients simply charge a convenience fee
• You can charge a fee in place of reimbursement, or on top of
• Fees can range anywhere from $30 to $125 per visit depending on the length of
the visit
Charge Your Patients Directly!

29. Review of the Steps
1. Determine the type of telemedicine (live video)
2. Define your use case (you can also narrow down your payers at this point and skip a couple of the next steps if not relevant)
3. Review Medicare guidelines and see if your use case is eligible for reimbursement
4. Research your state Medicaid guidelines and see if your use case is eligible for reimbursement
5. Call your private payers and ask for their telemedicine guidelines
6. Decide which payers you’ll go through, if not all
7. Call eVisit or connect with your local telehealth resource center for questions
8. Train your staff on the workflow
9. Verify that your patient's insurance will cover telemedicine before you start
10. Charge a convenience fee (in place of, or in addition to your reimbursement)
Here are the key steps for figuring out telemedicine reimbursement for your
practice:

30. Other Reimbursement Resources
• List of state Medicaid websites
• Medicare Telemedicine Guide
• List of Medicare telemedicine CPT codes
• ATA state policy matrix
• Telehealth Resource Center State Policy Map

31. See our telehealth software
in action
Schedule a free demo!
sales@evisit.com
(844) 693-8474
evisit.com/request-a-demo/
Sept 2015
Follow us
@eVisit
evisit.com/blog/
Treat your patients anytime,
anywhere….and get paid!