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Telemedicine: The Great Medicaid Disruptor

In a matter of weeks, the pandemic transformed healthcare delivery for Medicare and Medicaid. Telemedicine, a previously little-used channel of doctor and patient engagement constrained by significant restrictions, was suddenly the most common form of healthcare interaction. Amid the global pandemic, leveraging telehealth-based technology (primarily video and voice services) provides patients and practitioners a means to rapidly transition to “no-contact” healthcare delivery.

To support this need for contactless healthcare, CMS lifted several federal rule restrictions on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

Examples include:

  • Allowing non-HIPAA secured platforms (Zoom, Skype, video-enabled phones) to host the online examination
  • Waiving interstate provider licensure restrictions
  • Waiving originating site restrictions
  • Waiving requirements for prior doctor-patient relationships
  • Allowing audio-only communication in some situations
  • Streamlining billing and payment options

CMS authorized states covering Medicaid and CHIP services that were provided via telehealth with great flexibility regarding utilization and billing. States have the option to determine whether to use telehealth; what types of services to cover; where in the state it can be used; how it is implemented; what types of practitioners or providers may deliver services via telehealth; and reimbursement rates. States have full discretion to select from a variety of HCPCS codes and modifiers to identify, track and reimburse for these services.

CMS published and subsequently expanded a list of HCPCS and CPT-4 procedure codes that may be billed in a telehealth engagement. Many of these procedures are covered only for a limited period during the public health emergency. To further drive telehealth, CMS released a new supplement to its State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, COVID-19 Version that provides numerous examples and insights into lessons learned from states that have implemented telehealth changes.

Because of these waivers and tools, CMS reports that Medicaid and CHIP telemedicine services increased 2,600% during the March through August timeline compared to the prior year. The coverage for many of the newly authorized telehealth services is only for the duration of the pandemic healthcare emergency declaration. However, most of the telehealth procedures are expected to become part of the ongoing, optional Medicaid covered services. 

Benefits, processing and utilization review

Gainwell Technologies enabled several states to adapt to these changes in record time. The urgent relaxing and waiver of requirements on delivery and billing of telemedicine services required most Medicaid Enterprise Systems to immediately modify three processing areas:  Benefits, Adjudication and Program Integrity/Utilization Review.

Time-bound modifications were required to covered services, benefits configuration and pricing spanning 200 procedures. More than half of these newly authorized codes are approved for only a temporary status. Each state could determine which set of available 1135 waiver conditions they would apply for and which services they would cover.

Generally, Gainwell clients accommodated the new service delivery model through configuration within the benefits and pricing rules to enforce the new policy parameters.  In some cases, states had to relax existing edits to require manual review of more claims to allow the affected claims to pay.

While some portions of the federal restriction easing are temporary, telemedicine is here to stay and will continue to play an important role in the future of healthcare. All states will need to understand the impact of these policy changes to determine the best path forward when determining the ongoing support of telehealth services.

With the pressing need to authorize and encourage healthcare delivery with less physical interaction, the new guidance has also opened the door to potential improper billing practices or even fraud. Early reviews indicate upcoding in both complexity and duration of online procedures. There is also early evidence of telehealth as an entry point into coordinated overbilling. This isn’t surprising. Even before COVID-19 telehealth was a gateway for Medicare fraud. In 2019 the Department of Justice indicted numerous providers on a $1.2 billion kickback scheme where telemedicine claims led to Durable Medical Equipment overbilling.

To mitigate these risks, states should implement targeted query studies within their program integrity/utilization review program to identify intentional, inappropriate billing practices. These targeted algorithms should look within the telehealth claims as well as search for patterns of unusual follow-on related services.

Gainwell Technologies serves as a trusted partner, providing configurable solutions that enable rapid deployment of policy changes. The ability to measure impact of policy changes, coupled with the ability to discover anomalies or inconsistencies using intuitive drill-down and drill-through techniques, gives our state partners the ability to act and shape their policy based on tangible results. So, states can proceed with confidence when it matters most.

About the Author

Jeff Strand is a business solution architect with more than 30 years of healthcare industry experience. He is a member of the MITA Governance Board and is a co-chair of the National Medicaid EDI HIPAA (NMEH) sub-workgroup on MITA. At Gainwell he helps define modular healthcare solutions to align to the CMS Medicaid Information Technology Architecture and evolving State and Federal requirements.