What Is Cms Definition of Telehealth
While telemedicine has always referred to remote clinical services, telemedicine can refer to broader services, including: The potential expansion of telemedicine coverage raises concerns about the potential for fraudulent activity. In recent years, there have been several major fraud cases involving telemedicine companies, most of which involved filing fraudulent claims for items, services, and tests with Medicare and other insurers that were never given or administered to patients. HHS`s Office of the Inspector General (OIG) is conducting several studies to assess the appropriateness of using telemedicine during public health emergencies, including an analysis of provider billing patterns to identify providers who may pose a risk to program integrity and a review of Part B of telehealth services to ensure that the Services meet Medicare requirements. The Medicare Payment Advisory Commission (MedPAC) recommended that Medicare apply additional audits to investigate outliers of clinicians who provide more telemedicine services than others, and require face-to-face visits before clinicians can order expensive equipment or services for beneficiaries. There are three main types of virtual services that doctors and other professionals can offer to Medicare beneficiaries, which are summarized in this factsheet: Medicare telemedicine visits, virtual recordings, and electronic visits. Telemedicine, telemedicine and related terms generally refer to the exchange of medical information from one place to another through electronic communications. The Centers for Medicare and Medicaid Services (CMS) defines telemedicine as real-time, interactive two-way communication between a patient and a remote physician or practitioner via telecommunications equipment that includes at least audio and video equipment. Telemedicine, the provision of health services to patients by providers who are not in the same location, has escalated rapidly during the COVID-19 pandemic, both among private insured patients and Medicare beneficiaries. Prior to the pandemic, telemedicine use by traditional Medicare beneficiaries was extremely low, with only 0.3% of traditional Medicare beneficiaries using telehealth services in Part B in 2016.
Between 2019 and 2020, the number of telemedicine visits to traditional Medicare increased 63-fold. In the first year of the pandemic, a total of more than 28 million Medicare beneficiaries used telehealth services, including nearly half (49%) of Medicare Advantage participants and nearly 4 in 10 beneficiaries (38%) under the traditional Medicare plan. Medicare Advantage plans must cover all Part A and Part B benefits covered by traditional health insurance. In addition, since 2020, Medicare Advantage plans have been able to offer telemedicine services that are not routinely covered by traditional Medicare (i.e. not during the COVID-19 public health emergency), including telehealth services for participants in their homes and services outside of rural areas. By 2022, virtually all Medicare Advantage plans (98%) offer telemedicine services. In the first year of the COVID-19 pandemic, 49% of Medicare Advantage participants used telemedicine services. Prior to this exemption, Medicare could pay for telemedicine only to a limited extent: if the person receiving the service is in a certain rural area and leaves home and goes to a clinic, hospital, or certain other types of medical facilities for the service. If no further legislative changes are made, Medicare reimbursement for telemedicine will revert to pre-public health emergency rules after the 151-day post-emergency period. Under these rules, only physicians and certain other practitioners (such as physician assistants, clinical social workers, and clinical psychologists) are eligible to receive Medicare payments for telemedicine services provided to eligible beneficiaries of traditional Medicare, and they must have treated the beneficiary receiving the services within the past three years.
The contribution of beneficiaries to telehealth services did not change during the health emergency. Medicare covers telehealth services under Part B, so traditional Medicare beneficiaries who use these benefits are subject to the $233 Part B deductible in 2022 and 20% coinsurance. However, HHS`s Office of the Inspector General has given providers the flexibility to reduce or waive cost-sharing of telemedicine visits during the COVID-19 public health emergency, although there is no publicly available data on the extent to which providers were able to do so. Most traditional health insurance beneficiaries have supplemental insurance that can cover some or all of the cost-sharing for covered telehealth services. Medicare Advantage plans have the ability to change cost-sharing requirements as long as they meet actuarial equivalency standards and other CMS requirements. Policymakers are considering various proposals to extend some or all of the existing flexibilities related to telehealth services under Medicare beyond the public health emergency, and many have expressed support for the idea. Telemedicine bills introduced in the 117th Congress include proposals to expand some Medicare telehealth services and permanently remove geographic and geographic restrictions on Medicare telemedicine coverage. Other laws would permanently cover some of the telemedicine extensions provided during the public health emergency and expand the circle of providers eligible for payment for telehealth services covered by Medicare. Other bills seek to assess the impact of expanding telehealth services in Medicare and Medicaid on the use of telemedicine visits, including demographics. Expanding telemedicine coverage beyond the COVID-19 public health emergency could impact the quality of patient care, as well as program and recipient spending. Expanding telemedicine coverage has the potential to improve access to needed care, but the impact of telemedicine on communities of color is not yet clear, with research showing both higher usage in disadvantaged neighborhoods and lower usage among black and rural Medicare recipients than among white beneficiaries. In addition, expanding telemedicine coverage would likely result in an overall increase in Medicare program spending: CBO has achieved five months of expanded telemedicine coverage, which is included in the 2022 CAA, which costs $663 million.
However, some telehealth services may replace self-care, such as a behavioral health visit, although easier access to telemedicine can lead to an overall increase in visits and costs. Other telemedicine services may not entirely replace the need for (or occurrence) of an in-person visit, such as when laboratory work is deemed necessary. Medicare Advantage plans have the option to waive certain coverage and cost-sharing requirements in the event of a disaster or emergency, such as the COVID-19 pandemic. The CMS has indicated to plans that they can waive or reduce cost-sharing for telemedicine services, provided the plans do so consistently for all members in a similar situation.
