Few private claims for patient-provider emails require out-of-pocket payments, analysis finds

Fewer than 1 in 5 claims related to email messages between patients required a private health plan member to pay out of pocket, and those that did paid a median $25, according to a new analysis seeking to characterize the controversial billing policy.

The incidence of email messaging spiked in the months after the introduction of new billing codes at the top of 2020 and then settled through much of 2021 at roughly twice the level seen in January 2020, Peterson-KFF Health System Tracker wrote in its review of 2020 and 2021 private insurance claims data gathered from the Health Care Cost Institute.

These encounters—which represent email correspondences that require at least five minutes of a provider’s time—represented one out of every 73 office-based evaluation and management (E&M) visit claims at their height in April 2020 but averaged out at one per 192 office visit claims through 2021, they found. Payments for email messaging claims comprised about 0.4% of E&M office payments for the entirety of 2021.

The median payment across both years for plans and patients combined was $39. When patients were required to share costs, half of their payments landed within the $14 to $40 range; for plans, the middle 50% of paid claims ranged from $39 to $59.

Just over half of the two years’ email messaging claims came from physicians, with physician assistants and nurse practitioners making up the majority of the remaining non-physician provider claims. While claims from physicians were spread out between shorter (five to 10 minutes, 43%), moderate (11 to 20 minutes, 36%) and longer (21 or more minutes, 20%), nearly all email messaging claims (96%) from non-physicians were categorized as longer correspondences.

On the subject of those messages, over a third of the claims in 2021 included general medical consultation diagnosis codes. Low back pain (5.3%), acute sinusitis (3.1%) and unspecified counseling (2.7%) were the next most frequent. Most claims were billed by primary care providers in family medicine (32.6%), internal medicine (32.3%), pediatrics (9.8%) and OB-GYN (5.2%).

Data from the group’s analysis come just a few months after a JAMA research letter that similarly outlined an initial post-COVID spike in messaging charges that dropped off, but persisted, through at least September 2022. That review of Trilliant Health’s all-payer claims database found that at least 471 different organizations had billed at least 50 email visits during the third quarter of 2022.

The decision to begin charging for some email messages by bigger names like Cleveland Clinic sparked pushback from consumers and advocacy groups that characterized these policies as a new way for hospitals to nickel-and-dime their patients. The chance to incur a charge can also lead to changes in care-seeking behaviors, as UCSF Health found when its weekly messages dipped once the system began informing patients of potential charges.

Peterson-KFF Health System Tracker’s researchers noted that the decision to charge “is up for debate.” Providers have said the charges still aren’t making up for the increased workload of responding to emails, while payers have described the charges as a contributor to higher spending and increased health premiums, they wrote.

As for the patients’ out-of-pocket burdens, “it’s unclear if private health plans will require patients to share costs for more of these in the future,” the researchers wrote.