Months into the COVID crisis, doctors and patients have become accustomed to telemedicine. But some clinicians still face difficulties getting patients on video calls -- and have to pay the price.
Todd Maltese, DO, a neurologist and sleep medicine specialist in Ronkonkoma, New York, closed his brick-and-mortar clinic at the start of the pandemic, maintaining his practice with virtual visits. As months passed, video calls got easier -- but not for all patients.
"You will still get those patients who don't have a computer with a webcam, or who don't have a smartphone," Maltese told 鶹ý. "Most patients are older, and a lot of them have trouble getting on."
When patients are unable to access video technology, Maltese conducts their visit over the phone. But there's one issue: the reimbursement loss is significant.
Maltese said that a 15-minute video call might be reimbursed anywhere between $50 and $75. For a 20-minute phone call, however, he gets reimbursed between $10 and $20.
"It's a huge difference," Maltese said. "Just because I can't see their face doesn't mean that I still can't make the same complex diagnosis, and come up with a complex treatment plan. So, to spend 20 minutes on the phone and get 80% less doesn't make sense."
Months into the COVID pandemic, doctors are still struggling to get reimbursed for telemedicine appointments. Insurers have instituted pay parity policies between telephone-only and video visits because of the crisis. But despite policy expansions, providers told 鶹ý that compensation is still unclear. Many still continue to grapple with patients' access to technology, billing codes, and policy variance across insurers.
Inequities in Tech Access
Karen Guerrero, MD, a dermatologist in suburban San Antonio, said that older patients are not always comfortable attending a video visit. Because of the shift to telemedicine during the pandemic, she said her reimbursements have suffered.
"I would say probably half the patients had difficulties with technological knowledge," Guerrero said in an interview. "It was more stressful than helpful for them."
Guerrero conducts video visits on FaceTime or Doxy.me, but video calls often have disruptive feedback, poor resolution, or irregular connectivity.
"I prefer to do everything on the phone," she said. "I just use video for the exam."
Loosened regulations allow patients to send photos, so Guerrero can see their condition and discuss treatment on the phone. This alternative, she said, is easier for patients who struggle with video appointments.
Many doctors have faced similar complications with video technology, according to Ateev Mehrotra, MD, MPH, associate professor of healthcare policy at Harvard Medical School in Boston. While many attempt video calls on various platforms, challenges with internet connection or teaching the patient video technology has made some doctors double as IT support.
"The dirty secret is that a lot of visits have been phone visits," Mehrotra said in an interview. "The video visit just isn't happening at the same degree because of all of those kinds of issues."
Mehrotra said that in the context of the pandemic, covering audio-only telemedicine visits provided a lifeline to vulnerable populations who may have struggled to get in-person care. But in the long-term, he recognizes that phone-only telemedicine has limitations.
"There's never an instance where an audio visit would be better than an audio and video visit," said Judd Hollander, MD, who directs the telemedicine program at Thomas Jefferson University in Philadelphia. "That being said, a phone call virtually always works and a video visit can have all kinds of hiccups."
During the pandemic, Hollander said that most payers are paying reasonable rates for both phone and video telemedicine calls. "But there's not a day, even with one named insurer, where you can say they covered all of it, with 100% certainty."
Billing Code Confusion
When the Centers for Medicare and Medicaid Services (CMS) instituted in April, it increased reimbursements for phone services from $14-$41 up to $46-$110, according to a press release. The agency also waived the video requirement for certain evaluation and management (E/M) services provided via telehealth.
But clinicians say despite parity policies and the abandoned video requirement, billing codes for audio-only calls have not changed. Medicare still requires physicians to report typical telephone codes, and they are paid comparably to an office visit or telemedicine service, according to .
Arthur Guerrero, MD, an endocrinologist (and Karen Guerrero's husband) who runs a practice of four doctors near San Antonio, said that while insurers have removed the video requirement, reimbursement for audio and video calls are still different dependent on how they are coded.
Guerrero said a lot of his patients are considered "more complicated," and he usually codes a level four or five. But the audio-only codes still do not pay the same as the in-person visit that he would normally code for these patients. "The office visit is different, and I think it ought to be the same," Guerrero said.
Michael Grad, MD, a cardiologist in Austin, said audio-only calls should pay the same as video visits in theory. But in reality, they will only pay the same if documented correctly.
"The majority of my cardiovascular patients are a 99214 [level four follow-up patient] which traditionally compensates the physician three times as much [as a phone call lasting 20 minutes]," Grad said. "You're doing the work, but historically, you're truly not getting paid similarly for your time."
Billing codes for phone evaluations are typically determined by time. Expanded telemedicine coverage has temporarily allowed phone calls to be billed at the same rate as some E/M CPT codes, which are based on complexity of care. But the reimbursements may still be unclear.
"Audio-only gets a little bit gray," Grad said. "Many physicians don't know if they're truly getting compensated under the new changes and most don't have the time or energy to follow that up."
Differences Across Payers
Medicare and most large commercial payers have approved pay parity for phone and video visits. But Maltese, the neurologist, said that there is still uncertainty about which insurers have adopted expanded policies -- and how long the policies will last.
"Right now it's kind of confusing because you don't know who is allowing what," Maltese said.
According to created by the American Medical Association, a few commercial insurers do not cover phone-only and video calls at the same rate, including Blue Cross Blue Shield North Dakota, and Horizon Blue Cross Blue Shield New Jersey.
But despite parity requirements, the CPT codes accepted by different insurers for audio calls are inconsistent. Most insurers accept typical phone evaluation codes (99441-99443), while larger payers like Cigna, Excellus Blue Cross, United Healthcare Commercial and Medicaid insurances, and Wellmark Blue Cross Blue Shield accept codes for evaluation and management services (99201-99215).
Some plans have even rejected parity between audio-only and video calls. CMS does not allow doctors to be reimbursed for risk assessment visits for their Medicare Advantage patients, a decision that has received pushback from clinicians.
"Everything is still in a pretty good state of flux," Arthur Guerrero told 鶹ý. "And just to make things simpler, everybody should just use the same code."
Amid uncertainty in telehealth regulations, Maltese said that his billing department has to re-process claims to make sure doctors are getting paid correctly. "There's nothing standard across the board," he said.
For many, the main uncertainty in telemedicine expansion continues to be how long the policies will last. Insurers continued to extend the expansion as the pandemic continued, and providers don't know how long they'll be able to bill for phone and video appointments.
"It's hard to keep track of everything," Maltese said.