More health systems are billing for electronic patient-provider messages, study shows

Charges for electronic, asynchronous clinician-patient messaging — or e-visits — have persisted in the wake of an early-2020 spike during the COVID-19 pandemic.

As providers continue to bill patients for messaging their doctors it suggests that “health system interest in e-visit billing has evolved from a short-term pandemic necessity to a potential long-term source of revenue,” researchers wrote in a new JAMA research letter published Wednesday.

The messages are often delivered through patient portals and EHR systems and can range from quick clarifications to prolonged back-and-forth.

Health systems like Cleveland Clinic made waves when announcing permanent policies to attach a bill to certain messages, which they say is necessary to justify the time spent by a clinician responding to numerous online inquiries.

To explore how adoption of these billing policies may have changed, researchers reviewed Trilliant Health’s all-payer claims database for visits from Jan. 2020 to Sept. 2022 with a CPT code indicating an e-visit. The aggregated and cleaned source pulls from commercial payers, clearinghouses and the Centers for Medicare and Medicaid Services (CMS), and on average include claims tied to nearly 273 million unique patients per year.

Among these, the researchers found an average of about 103,000 monthly e-visit claims in 2020, 77,000 in 2021 and 101,000 in 2022, according to the study. The monthly claims peaked in April 2020 at more than 202,000, plummeted to a low of about 64,000 in June 2021 but then returned to 107,000 by Sept. 2022, the study’s final period.

At least 471 unique organizations billed for at least 50 e-visits during the third quarter of 2022, which was up nearly 40% from the same time a year prior, the researchers found.

The CPT indicating a five- to 10-minute visit comprised about 45% of all claims, while 11- to 20-minute e-visits claimed 40% and 21-minute-or-longer e-visits filled the remaining 15%. Acute diagnoses, like acute sinusitis (7%) and urinary tract infection (7%), were most frequent among shorter e-visits while chronic conditions, like hypertension (18%), led the longer e-visits.

“This variation may suggest that shorter, lower-cost messages may substitute for synchronous acute care, whereas longer, more complex messaging is more often an additional care touch point,” the researchers wrote in the journal.

The new study did not explore what portion of electronic messages were or weren’t billed, the researchers noted, and more research is needed to explore other questions relevant to adoption and policy; for instance, whether e-visits are cost-effective and whether they substitute for other types of encounters.

Several of the same researchers published a study reviewing volume trends in the months after UCSF Health began billing for a subset of e-visits.

There, they found that implementing and informing patients of potential charges cut down the average weekly number of messages from 59,648 to 57,925 and average weekly message threads from 19,739 to 16,838. The “immediate level change” was accompanied by a nearly fivefold increase in weekly “e-visits” billed at clinicians’ discretion—from about 50 to more than 230—and no significant changes to scheduled in-person visits or unscheduled phone calls.