Everyone should heed this experience…if the claims are not getting paid as expected, get in touch and fight for parity payments…
If you have RVU-based contracts, which many of you do, I’d love to understand how and why the payors would be able to pay less than the full value of the RVU service.
Health insurance companies are behaving like organized crime.
CT BCBS paying one fixed rate for telehealth about 1/3 of what we should get for the average visit. In the past they have been unreachable, non negotiable and can’t get a rep. Put in a hassle factor form but anyone in CT have a contact?!
Any insurances paying for Telehealth well visits ?
Yes - it’s very regional. VT BCBS, for example, is paying for well visits via telehealth.
We have two local payers who have agreed to cover well visits via telehealth, nothing from the national payers yet. The Governor (Mass) is requiring payers to reimburse all medically necessary, clinically appropriate visits via telehealth at the same rate as in person visits.
We have been doing “WCC” via telehealth in my San Antonio practice for 9 days now. We made the decision expecting to not get paid. We had a robust discussion about R/B of doing so and we fell on the side of doing them. Every kid 4m and older is telehealth only. Car visits for shots and any f/u exam needed. We can discuss the merits of it elsewhere, but the financial plan is as follows.
We have worked creatively to identify an algorithm to follow to identify best methods of payment, including 9938X and 9921X. I am in Texas and there is payment parity for all fully funded/non-ERISA/DOI-governed plans for telehealth WCC, according to our local state reps. But that is clearly a minority. The rest we are investigating and calling on and getting reference numbers to back us up. We have held claims in an effort to give state and federal gov’t time to get things together. Yes, we may be exposed to audits. We know that.
If you want telehealth parity, my impression is that nothing is going to work until we get a federal mandate that telehealth WCC will be covered with parity. I think it is up to the AAP lobby and whatever national pull we each have. The states are going to wash their hands for all non-state regulated plans, nor do I know if they even have authority to mandate higher anyways.
Virginia Anthem is telling parents (and providers that bother to call) that they will cover all preventive health codes delivered via telehealth.
Our Anthem rep continues to instruct us to visit online for the most upto date info…https://providernews.anthem.com/virginia/article/information-from-anthem-for-care-providers-about-covid-19-2. We have not been able to find any documentation supporting and wcc visits via telehealth. HEDIS also added language this year that specifically states “NOT to count services provided via telehealth when reporting” on WCC measures. Has anyone heard of additional guidance from them relaxing their restrictions on measures?
A community physician stated she received guidance from a commercial payor to remove the Modifier and change the POS back to 11 which seems to have spread like wildfire amounts her colleagues however, our billing manager is advising that this would be considered a fraudulent claim… any thoughts?
Another suggestion was to do an initial screening via telehealth with an office/car visit within 7-days for the physical exam any any vaccines making the billable code a true in-office visits and not telehealth coded. This is also something that was discussed briefly on one of our weekly calls here and on the Colorado Childrens Hospital podcast. Has anyone attempted this?
The advice to effectively pretend you did a well visit in the office when you didn’t seems fraught with risk.
Dr. Diasio posted an example of TN Medicaid’s instructions for doing EPSDT visits for kids >2y in the webinar last night. I am hoping that in the next week or two there will be a solution shared by the AAP, AMA, and others.
NC medicaid is currently just doing sick visits. via telehealth- well is “coming soon”
TN medicaid is doing well visits >2yo via Telehealth!
Yes, totally typing too fast! Post edited!
Note that VERMONT also allows preventive visits for patients >2yo using telemedicine - all payers.
We have set up a program we are labeling “Fast & Flexible”. We are using the down time to schedule as many pre-physicals via telehealth as possible. Anything that can be done remotely is done that way. When the restrictions are lifted, we plan on offering a 15 minute quick visit to complete the physical. At that time, we will complete the essentials (height/weight/BP/vision/hearing, a physical and vaccines). It doesn’t help the current cashflow situation, but when we get going we will be primed. This plan is helping us catch a lot of adolescents who normally flake on their appointments. Also, it’s a good time to go through all the charts and get everyone current.
Your planning and attitude here deserve praise. Awesome. Keep it up.
When you say “It doesn’t help the current cashflow situation,” I wonder why not? Are you billing for the initial visit?
Billing for this previsit is problematic. It’s really part of the well check. So what are the options? Not many.
If we bill it as a well check visit, we wouldn’t get paid because that not billable as a telehealth visit. Even if we could bill it as a well check via telehealth, when they come in for the remainder of the exam, we could not use that code again (only one well check is billable per year for older kids), thus billing for vision/hearing, etc. would get denied.
If we billed it as another code – it’s stretching the limit of ethics because it’s part of the well check we are doing. Also, some of the codes we could conceivably use may push a copay on the patient. Patients don’t expect a copay with well checks and billing would get inundated with unhappy people.
A significant portion of our cashflow is vaccines. We depend upon the profit of vaccines to survive and the cashflow of vaccines to pay bills. This can’t be accomplished via telehealth. I don’t see how any pediatrician can survive on telehealth. It doesn’t pay enough. If we can create a situation where we get more well checks in per day, then it becomes worthwhile.
this is exactly our plan, and our conundrum. we do want to get the kids back in for hearing/vision/bloodwork and vaccines as indicated. if we bill the TH well visit now and by some miracle DO get paid, i am not sure we will get paid for the other work done at the later date as it would require the well visit code. for now we are holding on billing the PE as we do not know from majority of our insurers IF we will get paid. welcome all thoughts on this!
In Texas, as of today, every major payer is falling in line and covering telehealth well visits at parity with in-person. It has taken a ton of calls and leveraging contacts to arrive at this conclusion. But we are now rolling out most all of the charges that we had not yet submitted but have performed. Most importantly in or region, most every self-funded/ERISA/ASO/TPA plan is following suit with their fully-funded counterpart and paying parity.
For those that so choose, this could be a viable financial option going forward. I personally believe this will be the case nationally. There are countless details that would need to work out operationally, as many above have mentioned. But the barriers to billing and getting parity seem to be lifting. Ad this to the basket of options you have available to continue to provide care without the fear of not getting paid.
*note, time frames for the viability of this parity vary by payers and range from month to month to June 4.
Perhaps we can have Paulie & Chip put together a webinar on the topic once some of this awful dust settles a bit?
From the AAP, just now:
This is such a big deal that I want to share the text from the announcement.
Remember, meanwhile, that you all heard the guidance about Bright Futures directly from the source RIGHT HERE a few weeks ago!
AAP issues guidance to ensure continued care for children during pandemic
by Trisha Korioth • Staff Writer
The AAP has issued new guidance to ensure children continue to receive ambulatory services during the coronavirus disease 2019 (COVID-19) pandemic.
To underscore the importance of access to pediatric care, Guidance on Providing Pediatric Ambulatory Services via Telehealth During COVID-19 emphasizes the need for pediatric ambulatory services to continue. These include in-person visits where community circumstances allow. New guidance addresses the provision of telehealth for health supervision visits and acute and chronic care visits through telehealth, delivered by general pediatricians, pediatric subspecialists and pediatric surgeons. It stresses that care should not be delayed during the pandemic, without delay inclusive of and with appropriate referrals. The guidance also urges full payment for telehealth visits at parity with in-person visits.
Other guidance released provides guidance to support the continued provision and follow up of essential newborn screenings and safety, infection control, and wellness in guidance related to child care settings that remain open, mainly aimed at helping those serving essential workers and their children during the COVID-19 pandemic.
Pediatricians have observed a significant decrease in in-person child health visits during the COVID-19 pandemic, which not only puts children’s health at risk but also places practices in jeopardy as they balance business financing and care delivery.
“It is imperative that we preserve the medical home and pediatric workforce during this crisis, and to do so, there must be payment at parity with in-person visits for other forms of care like telehealth,” said AAP President Sara “Sally” H. Goza, M.D., FAAP. “As the U.S continues to follow guidelines from our nation’s infectious disease experts during this pandemic, pediatricians are here to take care of our children and adolescents in multiple ways — in person, via telemedicine or by phone consultation.”
Well-child care should be consistent with Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents (4th Edition) and the corresponding Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (Periodicity Schedule).
If community circumstances require limiting in-person visits, the guidance urges pediatricians to:
- Prioritize in-person newborn care, newborn well visits and immunization of infants and young children through 24 months of age whenever possible.
- Continue well visits for children through telehealth, with the acknowledgement that some elements of the well exam will need to be completed in clinic once community circumstances allow.
- Complete in-person elements when circumstances permit. These elements include, at a minimum, the comprehensive physical exam; office testing, including laboratory testing; hearing, vision and oral health screening; fluoride varnish; and immunizations.
- Conduct acute or chronic care via telehealth and complete some elements of the acute or chronic care visit in clinic as indicated and when circumstances permit.
Full payment for recommended codes should occur at the time of the initial visit with the appropriate modifier and should be eligible for full payment if billed by the pediatrician no matter the child’s age.
Guidance on Newborn Screening During COVID-19 calls for continued bloodspot screening, early hearing detection and intervention, and critical congenital heart disease screening. The guidance recommends that pediatricians continue to follow federal and state guidelines on newborn screening and the uniform screening panel, and specific state guidance to procure results.
Follow-up on abnormal results often requires rapid intervention, making it especially important for parents to continue with newborn visits, Dr. Goza said. “As you all know, newborn screening saves lives, and we must be diligent in making sure all children are screened according to the guidelines from the state they live in.”
Guidance Related to Childcare During COVID-19 is consistent with Centers for Disease Control and Prevention guidance. Although much of the document is intended for those serving essential workers, pediatricians who work as child health safety consultants in their communities and those who might anticipate phone calls from families can consult the guidance for information specific to fever, personal protective equipment and other safety recommendations specific to COVID-19.
Pediatricians who have questions or concerns can email COVIDemail@example.com.