By Kathlean Downing, CPC, CDEO, CPMA, CRC, CEMC
Compliance Specialist, Risk Management, Blanchard Valley Health System

As we begin 2023, it is hard to believe that nearly three years have passed since the federal government initially declared a public health emergency (PHE). With the declaration of the PHE, the Centers for Medicare & Medicaid Services (CMS) and other commercial payers adjusted coverage policies, and the doors for telehealth were opened for a whole new world of healthcare to emerge. 

Coverage of these services was expanded to reduce exposure and help limit the spread of COVID-19. While telehealth can significantly expand access to health care, certain populations may have difficulty accessing or be unable to access technologies used for audio-video telehealth because of various factors, including financial resources, limited English proficiency, disability, internet access, availability of sufficient broadband and cell coverage in the geographic area. We might not see permanent expansion in telehealth coverage until these gaps have been filled so that all patients have the same access to care. 

As for now, these services have continued coverage due to the most recent extension of the PHE on October 13, 2022, by Secretary of Health and Human Services Xavier Becerra. Health and Human Services (HHS) has committed to providing a 60-day notice prior to the termination of expiration and it is expected that the PHE will once again be renewed through early April 2023, since no notice was given by the administration in November. 

Upon the end of the PHE, some telehealth policies will end immediately, other policies will have a 151-day allowance for transition that will start once the end of the PHE is announced, and some policies will remain. 

There were changes made for certain services that will allow for coverage, even after the end of the PHE. Legislative and administrative changes were made to behavioral/mental health services through the Consolidated Appropriations Act (CAA), in 2022. Implementation of the CAA will allow patients to be seen via telehealth for behavioral/mental health services in their home but once the PHE ends, the service will require an in-person visit with the telehealth provider prior to the telehealth services taking place. Subsequent 12-month in-person visits will be required to continue these services via telehealth.  The CAA also allows the use of audio-only (telephone) to be used to deliver mental health services.

At the beginning of the PHE, most states created allowances for providers to treat patients across state lines to help with the influx of patients requiring treatment. Most of these states have already rescinded this allowance. This means that providers need to be licensed in the state that the patient is in, at the time of service. For example, if a patient is seeing a provider in Ohio during the summer and goes to Florida over the winter, that provider cannot see that patient via telehealth for treatment of their condition(s), unless the provider is licensed to practice medicine in Florida. 

HIPPA privacy rule changes to telehealth services provided through certain communication types under the Telehealth Notification will change immediately with the end of the PHE. This change made allowances for services provided through FaceTime and Skype, even though the service may not fully comply with the HIPAA Rules. After the PHE ends, telehealth services will need to be completed through applications that meet HIPAA requirements. 

Other services have a 151-day extension. Coverage of these services will remain for 151 days after the PHE ends, as identified by the CAA. This extension covers the increased flexibility of patient geographic location and site location requirements. When the 151-day extension is over, Medicare will no longer cover services patients receive from their home, patients will need to go to a covered “originating” site for services. CMS will follow a list of services that can be completed along with a list of providers that can treat via telehealth when all criteria have been met. Medicare reimbursement for telehealth visits furnished by physical therapists, occupational therapists, speech language pathologists and audiologists will no longer be allowed. Medicare will no longer cover audio-only (telephone) visits for physical health encounters.

Commercial insurance companies will likely change guidelines for telehealth services or only pay for services that are provided through covered portals or with certain providers. Your commercial plan could still cover telehealth as an option, but you might need to go through your insurance payer portal for the service and will only be able to see the providers they have through their portal. There are also some plans that cover services only for certain diagnoses and/or with higher copays. 

Patients should check their insurance benefits for coverage of telehealth services. If your plan covers telehealth services, you will want to ask about the guidelines for coverage. Please understand that your provider does not get to make these rules, the rules are set by your insurance company. 

Providers should confirm that the expected encounter is appropriate for telehealth and that consent from the patient has been obtained and documented. Provider offices will want to verify the place of service (POS) and modifiers to make sure everything is correct before billing a claim. After the end of the PHE, you will want to review all rules and coding guidelines to make sure you are up to date. 

The end of the PHE will mark the beginning of payer audits on telehealth services. The Office of Inspector General (OIG) has already issued a report – Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic. In this report, the OIG has identified several program integrity risks associated with billing for telehealth services that were similar across multiple healthcare programs, such as risks involving inappropriate billing for the highest, most expensive level of telehealth services and risks related to duplicate claims and high-volume billing.