On January 5, the Centers for Medicare & Medicaid Services (CMS) issued guidance for State Health Officials clarifying that Medicaid and CHIP coverage and payment of interprofessional consultations (commonly and hereafter referred to as “eConsults”) is permissible, even when the beneficiary is not present. To be eligible for coverage, the eConsult must be for the “direct benefit of the beneficiary,” which CMS indicates is when (1) the service is directly relevant to the individual patient’s diagnosis and treatment and (2) the consulting provider has specialized expertise in the particular health concerns of the patient. This newsletter provides an overview of CMS’ new eConsult policy and highlights implications for states, Medicaid beneficiaries and providers.
What is an eConsult?
An eConsult is a telephone or internet-based consultation between two providers that is done for the direct benefit of the patient. The eConsult is typically initiated by the patient’s treating provider (primary care provider or specialist) who requests the opinion and/or treatment advice of a remote consulting provider (specialist) who has no direct contact with the patient. The consulting provider assists the treating provider in caring for the patient (e.g., diagnosis, treatment plan) without face-to-face, in-person contact with either the patient or the treating provider.
How did CMS change its eConsult policy? Why is this policy change notable?
This policy change allows payment for eConsults in Medicaid that can be billed directly by the consulting provider, increasing access to specialty care and treatment for millions of Americans. In CMS’ previous policy, Medicaid could pay for the consultation but only through the treating provider, not through direct billing by the consulting provider. This required states to pay the treating provider higher rates when engaging in an eConsult and then for the treating provider to reimburse the consulting provider for the consult.
CMS is now allowing states to reimburse the consulting provider directly for eConsult codes if the consultation is directly relevant to the individual patient’s diagnosis and treatment and the consulting provider has specialized expertise in the particular health concerns of the patient. Both the treating and consulting provider must be enrolled in the Medicaid program in the state in which the beneficiary resides, although the consulting provider may be licensed/credentialed in a different state. The policy applies using either synchronous (video or audio-only visit) or asynchronous (store and forward) telehealth technology. eConsults can be offered with respect to a broad range of services, including physician services, behavioral health and home health.
What are implications for states, Medicaid beneficiaries and providers?
Medicaid beneficiaries in states that opt to cover and reimburse for eConsults may experience more timely access to specialty care, which is a particular issue for some specialty services and in more rural communities. eConsults can also help beneficiaries avoid travel time associated with unnecessary in-person visits.
Given the potential for improving access to specialty care, a number of states have obtained authority through state legislation for or expressed interest in covering eConsults. States that choose to cover eConsult codes must submit a state plan amendment to CMS to add a payment methodology for the qualifying service, and should consider broadly communicating any related policy changes to their enrolled provider community.
In states that cover eConsults, treating providers will be able to access remote consultations without the responsibility of paying for the consulting provider’s time, and consulting providers will be paid directly by the Medicaid program for providing interprofessional consultation services. Providers may face additional enrollment requirements, as CMS notes that consulting providers must be enrolled in the state Medicaid/CHIP program in the state in which the beneficiary resides, although they need not be licensed or certified in that state. In addition, providers may need to update their workflows to align with eConsult billing requirements. For example, Medicare requires providers to obtain annual patient consent for eConsults and communicate with patients about potential cost-sharing. States may impose similar requirements; however, these are not required by CMS. Within the new guidance, CMS encourages states to avoid unexpected cost sharing for eConsults and consider eliminating (or modifying) prohibitions on same-day billing that may limit the use of eConsults, particularly within integrated care models.