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As COVID-19 has forced more physicians into telemedicine visits, getting paid has been a struggle, providers told MedPage Today.

Telehealth reimbursement during the COVID-19 pandemic has increased rapidly compared with its previously slow uptake, but providers say they're not being paid to the extent they are being promised -- or anywhere close to the amounts they made with in-person visits. That's partially due to a lack of clear information and inconsistent policies across the country's patchwork of insurance plans.

"It's been very, very confusing," said Todd J. Maltese, DO, who runs a Long Island neurology and sleep medicine practice with three providers. "There's no standard way of doing this. Every insurance company, they're asking for different codes and modifiers."

"We are all kind of making it up as we go along," said Arthur Guerrero, MD, an endocrinologist who runs a private practice with four providers in a small town just north of San Antonio, Texas.

While telehealth's popularity among patients and providers has been growing, both public and private payers have been slower to embrace it. The pandemic forced payers to begin picking up the tab for more types of telehealth appointments, for the simple reason that Americans have been ordered to stay home. Most medical appointments have not been deemed essential, pushing thousands of patients to meet with their providers online.

The Centers for Medicare & Medicaid Services (CMS) pledged that Medicare would reimburse providers at 100% of the in-person rate for many of these virtual visits, and private payers followed with similar policies. But providers, analysts, and other insiders say some bills are being returned and only partially paid.

The culprits: quickly morphing policies, complicated language in those policies, and insurers publicly promising "coverage" without revealing what exactly they will pay for.

Telehealth coverage "used to be certain -- you weren't getting paid," said Judd Hollander, MD, who runs Thomas Jefferson University's telehealth program and serves as its healthcare delivery vice president. "Now it's uncertain. ... It's utterly confusing."

Inconsistent Payments

Maltese asked his office manager to call insurance companies about billing when his practice began shifting from a 100% in-person model to its temporary all-telehealth model a month ago.

"Half the companies couldn't even give us information because they didn't know, and it's been a crap shoot from there," he said. While some have paid in full, other companies promised to pay at 100%, but then reimbursed for less, he said.

"Some we have no guidance, so we just bill what we think," Maltese said. "We (as an industry) have got to get the coding and billing down."

Maltese understands why companies may not want to pay in full: "We are not doing a full exam," he said. But, he noted, it's necessary because when he spoke to MedPage Today last week, it was still not safe to leave home in Long Island. Telehealth thus is "really our only way of checking on patients, so I believe right now we should be paid 100% of the rates."

Doctors also paradoxically find themselves spending more time per visit with telemedicine. It takes Maltese's patients on average 10 minutes to get their software operational, and several times he has spent a half-hour serving as his clients' IT consultant before starting an appointment.

"Most patients are not 20 and tech-savvy; most are older and need to be walked through it, and I don't have the staff to do it," he said. "I'm falling behind because I have other patients after them."

Additional Losses

Medicare promised patients it would waive copays during the pandemic. "So we are already looking at making only 80% of what we would make face-to-face" if forced to drop the copay, Guerrero said.

Then there is revenue lost to procedures that cannot be done via telemedicine, such as the retinal scans Guerrero's practice would typically perform for diabetics. "It's not a huge procedure, but if patients are not coming in, you are not getting it done, so it translates into a bigger loss than [going down to] 80%."

CMS also directed providers to designate a place of service when billing, initially asking them to enter a specific code. Providers say CMS then failed to reimburse to 100% when some of those bills were submitted; it was closer to 70%, Maltese said. Providers said CMS recently fixed the problem by asking for a different code.

"What we think today is different than last week," Guerrero quipped. To figure out if his staff correctly submitted a claim, he often asks physicians from other practices what they did. If his staff erred, then they must appeal, which can saddle efficiency.

Medicaid reimbursement policies vary from state to state. Some Medicaid administrators have elucidated these policies well, but some have not, said Clinton Phillips, CEO of Medici, an Austin, Texas-based telemedicine platform. Providers can turn to state websites and medical associations for answers, he noted.

Other policies are still in development, said Mei Wa Kwong, JD, who directs the Center for Connected Health Policy, a national telehealth resource center that provides technical assistance. Questions need to be answered concerning coverage for federally qualified health centers and rural clinics, for example.

Also, when insurers do cover telehealth, they often direct patients to top telemedicine vendors, where patients see the vendors' certified providers. But if patients want to see their regular doctors, those visits are not always covered. Some states have intervened to order that coverage, but not all, Kwong said.

Staying Online

Insurers have enacted numerous new policies and have taken other steps to enhance telehealth coverage, according to a compiled by America's Health Insurance Plans. AHIP declined an interview with MedPage Today, but a spokesperson said in an email: "By waiving cost-sharing for telehealth services and expanding telemedicine programs, health insurance providers are facilitating care."

The American Medical Association said it continuously updates with instructions for how providers can navigate the new telehealth payment landscape, .

The American Hospital Association also declined to speak for this story, but its site features advocating CMS for expanded and improved telehealth coverage.

Peter Antall, MD, a former California pediatrician who is president of the Amwell Medical Group, said he has not had issues collecting from its 55 private payers.

But such anecdotes are few and far between. Guerrero and Maltese said they can only survive about two or three more months providing primarily telehealth, and only if they can collect most of their bills.

"It's not like I'm trying to save up for a Lamborghini," Guerrero said. "I'm trying to make 100% [reimbursement] because that's what my employees' jobs hang on."

His specialty lends itself to telehealth and his practice is in demand because of a nationwide endocrinologist shortage, Guerrero said. Cardiologists, plastic surgeons, and even, in his wife's case, dermatologists, are not as fortunate.

"I don't know how some of these places will survive when it's over," he said. "It's scary."

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