This may have happened to you recently: your doctor called to check on you, chatting for 11 to 20 minutes, perhaps answering the question you contacted her office or asking how you respond to a drug change.
Your doctor was paid about $ 27 for this if you are in Medicare – maybe a little more if you have private insurance.
Behind these calls is a four-digit “virtual check-in” billing code created during the pandemic for telephone calls that only last in this range, which has generated tremendous interest among medical groups.
This is part of a much larger, increasingly heated debate: Should insurers pay for audio-only visits? And if they do, should they pay the same reimbursement rate as when the patient sits in the doctor’s office, as was allowed during the pandemic?
Cutting or cutting payments for audio only could lead providers to drastically cut telemedicine services, warn some groups of doctors and other experts. Other stakeholders, including employers who pay for health insurance, fear that paying parity for audio-only telemedicine visits could lead to overpricing. Will this lead, for example, to a stream of unnecessary callbacks?
Robert Berenson, a fellow at the Urban Institute who has spent much of his career studying payment methods, said that if insurers pay too little, doctors who are now accustomed to reimbursement will no longer be able to make the phone calls they could. free before the pandemic.
But, he added, “if you pay what they want on a par with personal income, you have a loss in the treasury. The correct policy is somewhere in the middle. “
Medicare billing codes are boring and confusing, but they are of great interest to doctors, hospitals, therapists, and others because they are the basis for paying for health care services in the United States. The Medicare verdict provides guidance and guidance for private insurance companies in developing their own benefit policy.
There are thousands of codes describing all possible treatments. There can be no payment without a code. The creation of codes and determination of the amount of reimbursement by Medicare, designed to reflect the amount of work done, is generating fierce lobbying from the interested business community. The American Medical Association receives a portion of the income from owning the rights to a specific set of payment codes for doctors. Other codes are developed by dental groups, Medicare and Medicaid service centers, or government Medicaid agencies.
The idea for the “virtual enrollment” code dates back to before the pandemic, in 2019, when Medicare turned it on to cover 5-10 minute phone calls from doctors so they could answer identified patients. Pays around $ 14.
When the pandemic struck, Congress and the Trump administration opened the door wider to telehealth, temporarily lifting restrictions – mostly those that restrict the provision of such services only in rural areas.
Meanwhile, this year, CMS added a billing code for longer “virtual checks” – calls lasting 11 to 20 minutes – with a charge set at about $ 27 a piece, with a 20% patient share as a co-pay. These calls are designed to determine if the patient needs to come in or otherwise have a longer evaluation visit, or if their health problems can simply be resolved over the phone.
In addition, doctors argue that allowing payment for audio-only services is a positive step for them and their patients.
“I take care of patients who travel two or three hours away and live in places where broadband is not available,” said Dr. Jack Resneck, Jr., a dermatologist and president-elect of the American Medical Association. “It is important for these patients to have a backup when the video option is not working.”
However, the focus on telephone-only assistance is a concern.
“Here’s an invitation to convert every five-minute call into an 11-20 minute call,” Berenson said.
The Medicare Code allows “other qualified healthcare professionals,” such as paramedics or nurse practitioners, to bill for these calls. Private insurers will set their own rules as to whether non-doctors can bill repeat calls. It is unclear what revenue stream sending such staff to these short phone checks could create for medical practice.
To avoid overuse, CMS has established a rule that the code cannot be used if the call is made within seven days of the assessment visit, in person or via telemedicine. The doctor also cannot bill the call if he determines that the patient needs to appear immediately.
However, when the medical emergency ends, like most payments only through audio. The accident is expected to last at least until the end of the year. Congress or perhaps the CMS could change the audio-only payment rules, and much more lobbying is expected.
While virtual enrollment codes have become permanent, physician groups are lobbying for Medicare to retain a variety of other phone-only visit codes created during the pandemic, including several codes that allow doctors to bill for phone-only visits that the doctor potentially diagnoses. the patient’s condition and draws up a treatment plan.
For those considered audiovisual “assessment and management” visits, Medicare during a public health emergency paid about $ 55 for a call lasting between 5 and 10 minutes and $ 89 for a call lasting between 11 and 20 minutes – the same as and for an office call. visit.
“Whether we see patients at home, by video or by phone, we need the same codes” and the same payments because it requires a similar amount of work, said Dr. Ada Stewart, chairman of the board of the American Academy of Family Physicians. …
Many patients love the concept of telemedicine, according to Suzanne Delbanko, executive director of Catalyst for Payment Reform, a group representing employers who want to redefine how they pay for healthcare. And for some patients, this is the easiest way to see a doctor, especially for those who live far from urban areas or cannot take leave from work or away from home.
But, she said, employers “don’t want to be tied to paying more for it than they paid in the past, or as much as others. [in-person] visits when it is not quite the same for the patient. “
KHN (Kaiser Health News) is the national newsroom that publishes in-depth journalism on health issues. Together with policy analysis and surveys, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). The KFF is a charitable, non-profit organization that provides health information to the nation.