Telehealth reimbursement rules pit insurers against doctors

Before the pandemic, telehealth coverage was a Wild West. Insurers were free to adopt telehealth reimbursement at will, and often employers could exclude these benefits from their plans.

When the coronavirus disrupted in-person care in early 2020, the state and federal government moved quickly to create temporary rules. In Massachusetts, the governor’s emergency rules required MassHealth and commercial insurers to provide broad coverage for telehealth visits and reimburse them at rates equal to in-person visits. The use of technology has exploded.

But insurers and providers disagreed on how to turn this temporary framework into a permanent policy. Insurers said equal reimbursements were not needed for a digital service that could save the state money. For their part, providers said the costs of providing care had not changed and that uneven reimbursement would discourage use.

Legislation of January 2021 fixed the new ground floor. The law stated that insurers must permanently cover telehealth for behavioral health visits at rates equal to in-person visits. For a two-year period ending in 2022, telehealth visits for primary care and chronic conditions would also be covered, under the law, at rates equal to in-person visits. Subsequently, reimbursement rates in these areas would be subject to negotiation between insurers and hospitals. The Division of Insurance undertook to create regulations to implement the law.

More than a year later, insurers are still waiting for these regulations. A spokeswoman for the Division of Insurance did not respond to requests for comment.

In the absence of regulation, the state’s largest insurer, Blue Cross Blue Shield of Massachusetts, filed its own plan with the Insurance Division, a policy that came into effect in April. Insurer policy defines behavioral health, primary care, and chronic care primarily by the type of practitioner who provides them, rather than by the service. For vendors who do not meet the law’s “pay parity” requirements, Blue Cross will pay them 80% of the in-person visit. The insurer noted that, in some cases, it covers services at the in-person rate, regardless of who provides them, such as psychotherapy.

Garofalo’s services are covered for now as a primary care physician. But after December, Garofalo fears being reimbursed 20% less than a psychiatrist when providing mental health care during a telehealth visit. Blue Cross Blue Shield said it did not decide on reimbursement for primary care providers after December.

“There is no real medical rationale to justify a psychiatrist being paid full rate and a family doctor being paid 80% of that rate,” said Garofalo, who is also a member of Massachusetts. Medical Society. He said on average, 15-25% of the patients he sees seek help for what would be considered a mental health issue, such as getting a prescription to manage anxiety or being diagnosed with ADHD. .

Other providers will see more immediate differences. Certain types of reproductive health care delivered via telehealth would be fully reimbursed if the provider was a primary care physician, but not if the physician was an OB/GYN, the Massachusetts Health & Hospital Association said.

Adam Delmolino, director of virtual care and clinical affairs at the Massachusetts Health & Hospital Association, which represents state hospitals, said differing interpretations of the law, in the absence of state regulation, open up the confusing for providers, contrary to the intent of the law to streamline the delivery of telehealth services.

“How busy and tense [doctors] As we come to the end of the pandemic, they shouldn’t have to check with every payor to see if they will reimburse in person during telehealth,” Delmolino said. “This creates administrative complexity. Providers need predictability when dealing with these policies.

Blue Cross representatives defended their interpretation of the policy, which was approved by the Insurance Division ahead of its implementation this month.

Matt Day, senior vice president of network payment innovation at Blue Cross Blue Shield of Massachusetts, said the insurer’s policy goes further than the law. This requires that self-insured accounts, typically large employers who pay their own claims, also have telehealth coverage policies. Usually, self-insured accounts are not subject to state insurance laws.

Compared to the 2019 policies, Day said today’s Blue Cross Blue Shield Massachusetts policies are expansive.

Mike Caljouw, vice president of government and regulatory affairs at Blue Cross Blue Shield of Massachusetts, said the policy balances coverage with affordability concerns.

“We believe our plan is consistent with that balance that the legislature has placed on this subject,” he said.

State Senator Cindy Friedman, who helped draft and pass the law, agreed that affordability issues should be a priority when insurers interpret the law. But she said the developing patchwork of policies could reverse some of the adoption of telehealth use while making health care more complex, something lawmakers have been actively working to reduce.

“I’m worried about that,” Friedman said. “You get into those nuances. Some people try to provide care, some try to save money, and some try to make money. It is one of the problems of our health system. I look forward to this being resolved and resolved quickly.

Friedman said his office has many conversations with the division about settlements and the division is working diligently on them.

At this time, other insurers have yet to file changes to their telehealth reimbursement plans, due to continued pandemic-related uncertainty, said Lora Pellegrini, CEO of the Massachusetts Association of Health Plans. , which has 15 of the state’s largest insurers among its members, although not Blue Cross. Thus, other insurers cover all telehealth services at in-person rates. Insurers are looking to next year, when they begin negotiating telehealth reimbursement rates for all services except behavioral health, as a time when they could negotiate lower rates.

“Each plan will come to this with a supplier individually. We believe telehealth is here to stay and is an important tool, but does not replace the in-person visit,” Pellegrini said.

Jessica Bartlett can be reached at Follow her on Twitter @ByJessBartlett.

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