Through Julie appleby December 8, 2021
Maybe this happened to you recently: your doctor called to see you, chatted for 11-20 minutes, maybe answering a question you contacted their office with or asking how you are reacting to a change in medication.
For this, your doctor was paid around $ 27 if you are affiliated with Medicare – maybe a little more if you have private insurance.
Behind those calls is a four-digit “virtual record” billing code created during the pandemic, for phone conversations lasting just in that range, which has generated inordinate interest from medical groups.
It’s part of a much larger and increasingly heated debate: should insurers pay for “audio-only” tours? And, if they do, should they pay the same reimbursement rate as when a patient is sitting in a doctor’s office, as was allowed during the pandemic?
Removing or reducing audio-only payments could cause providers to dramatically cut telehealth services, some groups of doctors and other experts warn. Other stakeholders, including employers who pay for health coverage, fear that pay parity for audio-only telehealth visits could result in overcharging. For example, will this lead to a flood of unnecessary follow-up calls?
Robert Berenson, Institute Fellow at the Urban Institute, who has spent much of his career studying payment methods, said if insurers pay too little, doctors – now accustomed to reimbursement – may no longer make any follow-up calls they could have made. free before the pandemic.
But, he added, “if you pay what they want, on par with in person, you will have a race for the treasure. Good politics fall somewhere in between.
Medicare billing codes, although a boring and obscure topic, are of great interest to doctors, hospitals, therapists, and others as they form the basis of health care costs in the United States. United. The Medicare verdict serves as a benchmark and guide for private insurers in setting their own payment policies.
Thousands of codes exist, describing all types of possible treatments. Without a code, there can be no payment. The creation of codes and Medicare’s determination of a reimbursement amount, designed to reflect the amount of work involved, has sparked fierce lobbying from relevant business interests. The American Medical Association derives a large portion of its revenue from owning the rights to a specific set of physician billing codes. Other codes are developed by dental groups, as well as the Centers for Medicare & Medicaid Services or state Medicaid agencies.
The idea for a “virtual registration” code began before the pandemic, in 2019, when Medicare included it to cover five to 10 minute phone calls for doctors to respond to established patients. He pays around $ 14.
When the pandemic struck, Congress and the Trump administration opened the door wider to telehealth, temporarily lifting restrictions – mainly those limiting these services to rural areas.
Meanwhile, CMS this year added a billing code for longer “virtual recordings” – calls from 11 to 20 minutes – with a payment set at around $ 27 a piece, with the patient contributing 20% of the quote. -go. Such calls are aimed at determining whether a patient should come or have a longer assessment visit, or whether their condition can simply be treated over the phone.
And doctors say allowing payments for audio-only care is a positive step for them and their patients.
“I take care of patients who drive two to three hours away and live in places without broadband access,” said Dr. Jack Resneck Jr., dermatologist and president-elect of the American Medical Association. “For these patients, it is important to have a backup when the video option is not working.”
Still, the focus on telephone-only care has raised concerns.
“Here’s an invitation to convert every five-minute call into an 11-20 minute call,” Berenson said.
The Medicare code allows “other qualified health professionals,” such as medical assistants or nurse practitioners, to bill for such calls. Private insurers would set their own rules as to whether non-physicians can charge for follow-up calls. It’s unclear how much of a revenue stream spending such staff members on those short phone records would create for a doctor’s office.
To avoid overuse, CMS has made rules: the code cannot be used if the call takes place within seven days of an assessment visit, in person or by telemedicine. A doctor also cannot bill for the call if they determine the patient should present immediately.
However, when the health emergency ends, most audio-only payments do so. The emergency is expected to last at least until the end of the year. Congress or possibly CMS could change the rules on audio-only payments, and much more lobbying is expected.
As virtual registration codes have become permanent, physician groups are pushing Medicare to keep a host of other phone call codes created only during the pandemic, including several that allow doctors to bill for phone calls only to the pandemic. during which the doctor potentially diagnoses a patient’s condition and sets up a treatment plan.
For those that are considered “assessment and management” audio visits, Medicare paid approximately $ 55 for a five to 10 minute call and $ 89 for a call lasting 11 to 20 minutes, as for a cabinet call. visit.
“Whether we see patients at home, on video or over the phone, we need the same coding” and the same payments because a similar amount of work is involved, said Dr Ada Stewart, chairman of the board of directors of the American Academy of Family Physicians. .
Many patients love the concept of telehealth, according to Suzanne Delbanco, executive director of Catalyst for Payment Reform, a group representing employers who want an overhaul of the way they pay for health care. And, for some patients, this is the easiest way to see a doctor, especially for those who live far from urban areas or can’t take time off work or get away from home.
But, she said, employers “don’t want to be forced to pay more than they have in the past, or as much as others. [in-person] visits when it is not really the same value for the patient.