CMS physician payment proposal nudges open the door for telehealth

Telehealth advocates are rejoicing over last week’s physician payment proposal that would reimburse physicians for certain virtual interactions, a move that some see as a significant first step in overcoming the telehealth payment obstacle.

Buried in the 1,473-page proposed rule released last week by the Center for Medicare & Medicaid Services are several new proposals to pay physicians for virtual check-ins and reviewing patient photos or videos using asynchronous or “store-and-forward” transmission.

CMS also proposed adding new billing codes for “prolonged preventative services,” along with three new remote monitoring reimbursement codes recommended by ACT, The App Association.

Jennifer Breuer, a partner with Drinker Biddle, said the proposed rule is a “game-changer” for the telehealth industry if it is finalized in its current form.

“What this really would do is create some pretty broad-based reimbursement for telehealth services not just in rural locations and not just in a healthcare facility, as is currently the case,” she told FierceHealthcare.

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It’s clear CMS is still ironing out the details on the proposal. In its explanation of virtual check-ins, which would include basic telephone calls, the agency asked for industry input about what types of “communication technology” are utilized by physicians, whether or not to include frequency limitations and how physicians should document that the services are medically reasonable.

CMS also noted that the proposal paves the way for new substance abuse treatment pathways, including virtual medication-assisted therapy.

According to Mei Wa Kwong, executive director of the Center for Connected Health Policy, CMS was forced to perform some “mental gymnastics” to get around payments restrictions in Social Security Act, which limits telehealth payments to rural facilities.

Using the term “communication technology,” the agency said the scope of the law is limited to “a discrete set of physicians’ services that ordinarily involve, and are defined, coded, and paid for as if they were furnished during an in-person encounter between a patient and a health care professional.”

“We all know this is telehealth, but they aren’t technically calling it telehealth because they would be limited,” Kwong said

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According to the proposal, Medicare would pay $14 per visit for virtual check-ins, a fraction of the cost of a $92 patient visit. Although CMS estimates it would pay for less than 1 million visits in the first year of the program, utilization would eventually reach an estimated 19 million per year.

That 0.2% increase to Medicare costs would be offset by a 0.2% reduction in the “conversion factor” to maintain budget neutrality.

Whether that payment is high enough to incentivize physicians to utilize virtual technology remains to be seen, but experts say it is added reimbursement for something many physicians are already doing.

“I think what we’ve seen from hospital and health system clients, and others who have adopted telehealth already, they are finding different ways to incentivize physicians to participate,” Breuer said.

An opening for direct-to-consumer companies

While all of the proposals revolve around virtual communications with an existing physician-patient relationship, CMS did throw a bone to direct-to-consumer telehealth providers.

In outlining a new proposal that would pay providers that review asynchronous video or images captured by a patient, CMS asked for comments about whether there are certain cases—such as dermatological or ophthalmological services—where a prior relationship isn’t necessary.

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“For example, when a patient seeks care for a specific skin condition from a dermatologist with whom she does not have a prior relationship, and part of the inquiry is an assessment of whether the patient needs an in-person visit, the patient could share, and the dermatologist could remotely evaluate, pre-recorded information,” the proposal states.

Although it was a request for information rather than a proposed rule, Kwong said it was notable since it diverged from traditional policies, and potentially offered some insight into how CMS plans to approach telehealth in the future.

“That could help direct-to-consumer [companies],” she said. “Depending on what state you’re in, there are ways to establish that via telehealth.”