AAP Guidance: Telehealth Payer Policy in Response to COVID-19


We are starting to get our first payments from insurance companies for telemedicine visits. They are paying them the same as a face to face visit as is required, but they are not waiving the patient’s co pay and they are applying the approved amount to their deductible, if they have one. The insurance companies state that since it is not a visit for a COVID-19 diagnosis, they won’t waive these fees. I spoke with the president of the Illinois State Medical Society who is going to look into it. Wondering what other practices/states are seeing.

Absolutely the same insane response. Very frustrating! And across all private carriers, while our TNCare Medicaid companies are variable. Two are paying appropriately, Amerigroup is not.

Remember, with commercial plans the only thing that plans are universally mandated to do is pay for televisits without cost sharing on COVID related diagnosis. You may have state parity for non-COVID reasons, but that only governs a small portion. Most are ERISA, which is all federal governed. The only thing the federal government mandated is coverage for COVID related diagnoses. We need the next step, federal coverage AND parity for all E&M. Until this is done, the only thing that will move the needle is public shame/lobby.

Sorry… what’s ERISA?

Great question!

So I am just a pediatrician and not an attorney, but this is my understanding on the matter as relevant to us in this discussion.

ERISA stands for The Employee Retirement Income Security Act of 1974. It is a “federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans.”

Most commercial insurance is either ERISA or non-ERISA. ERISA plans are “self funded”. They are delivered through a third party administrator, also known as a ASO. These are branded as “BCBS” or “Aetna” but are really just administrators. The insurance fund is within the business or group of businesses. Therefore only the federal government can regulate them and you have no ability to hold them accountable within your state’s Department of Insurance (DOI). Each plan (employer/group of employers) can decide their own rules and they often vary greatly for self-funded plans of the same brand.

The opposite is the fully funded plans (non-ERISA). In these plans, the actual insurance company (Aetna, BCBS) holds the funds of the premiums and serves as the fiduciary guardian. They take on the risk. These funds are regulated at the state level via the DOI. You generally have more leverage as a provider in holding these companies accountable as the DOI will standardize their requirements.

The devil in most of the details of your insured patients is that you have little enforcement ability for the vast majority of your commercial plans, because the vast majority of them are ERISA. Rapid moments of change like COVID make it glaringly obvious how little accountability exists in these duplicitous systems.

Anybody else please jump in and correct my errors and omissions. I am still on the learning curve myself.

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Please forgive typos; sent from Android


My only caveat to this is that your volume of ERISA plans is very regional.
In some parts of the country, ERISA plans are very much the minority.

I did not know that. Fascinating.

@eboebpa which insurance companies?
We are also in illinois… have been getting denials (aetna and cigna), bcbs did not pay parity.
UHC is the only one that did.

All of the payments we have received so far for telemedicine visits have been the same as our face-to-face visits - most are from BCBS and Health Alliance. We have very few patients on Aetna and Cigna so I don’t know how these insurers are paying in our area.