Managing Telehealth Claims

Telemedicine has significantly grown over recent years, primarily due to evolving technology and consumer demand. It’s anticipated that by 2025, the telemedicine market will have grown to $113.1 billion. In 2018, around 7 million patients in the U.S. accessed telemedicine services, which was a notable increase from 350,000 users in 2013. Unfortunately, payer reimbursement policies have failed to adapt as quickly to these new services.


What Is Telehealth?

Telehealth and telemedicine services are performed when a physician/other healthcare professional and the patient are not located at the same place. This means the patient may be at their own home communicating with a medical professional who is sitting at their office. Commercial payers do cover telehealth, but they have varying rules. Currently, it’s difficult to determine which facilities qualify as “originating sites”, whether modifiers are needed, and what the correct place of service actually is. Generally, telehealth payments have a professional fee that goes to the provider of the service at their remote site, as well as a facility fee that applies to the originating site where the patient is.


Issues with Telehealth and Billing

With how ambiguous and disparate telehealth rules currently are, it is a prime target for FWA. It was recently discovered by the OIG that more than half of the professional claims for telehealth payments did not have matching claims for the named originating site facility. Additional issues include significant inaccuracies in professional claims, such as: ineligible originating or distant site, non-covered service, or incorrect means of communication.

For instance, Medicare and many commercial carriers will not allow the originating (patient location) site to be the patient’s home. It must be one of the following instead:


  • Hospital
  • Provider’s office
  • Rural health clinic
  • Critical access hospital (CAH)
  • Federally qualified health center
  • Skilled nursing facility
  • Hospital-based or CAH-based renal dialysis center
  • Community mental health/crisis center


Additionally, telephone or online services like providers taking after-hours calls from their patients, are not covered telehealth services and won’t be reimbursed. It’s important for payers to have concise policies on these services so that they are understood by all parties.


How to Help

Sharecare Payment Integrity (formerly WhiteHatAI) can assist in the review of telehealth claims to identify irregularities in billing, as well as irregularities in utilization, unnecessary services, and a host of other issues in the delivery of services.


We can help to simplify review processes for telehealth claims via editing for valid modifiers, valid place of service, allowed frequency and covered telehealth services. Additionally, we have an edit for ensuring a professional claim for telehealth service also has an accompanying facility claim.

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