As highlighted in our September 2020 article, “Frequently Asked Questions: Telephonic Services as a Form of Telehealth,” in response to the COVID-19 pandemic, federal and state policy makers have significantly increased coverage and reimbursement for audio-only forms of telehealth. Audio-based telehealth continues to be necessary, especially for people who lack access to or cannot afford broadband Internet services, which are required for video telehealth. In addition, evidence continues to emerge that audio is an appropriate modality for patients receiving certain services that don’t require a physical or visual exam.i, ii,iii,iv Prior to the pandemic, very few state Medicaid programs covered and reimbursed for care delivered via audio, and Medicare offered limited coverage for a narrow set of virtual check-in services. In light of increased coverage and utilization of this modality during the pandemic, the Centers for Medicare & Medicaid Services (CMS) and some states are now acting to maintain permanent coverage for audio-based services.
Recent Medicare Activity Related to Audio Telehealth
CMS: On December 1, CMS finalized the CY 2021 Physician Fee Schedule Rule. Recognizing that audio visits could be beneficial for Medicare beneficiaries, CMS temporarily established HCPCS code G2252 for audio-only services of 11–20 minutes of medical discussion, which will be covered through 2021. This code supplements existing code G2012, which covers 5–10 minutes of medical discussion. Telephonic evaluation and management services, which offer higher levels of reimbursement for audio-only services and are currently covered on a temporary basis, will not be covered on a permanent basis once the public health emergency (PHE) ends.1
For more information regarding the telehealth components of CMS’ final CY 2021 Physician Fee Schedule Rule, please see our Manatt on Health article.
Medicare Payment Advisory Commission (MedPAC): On January 14, MedPAC hosted a meeting to discuss whether and how to permanently expand telehealth in traditional Medicare. With respect to payment rates for different modalities, commissioners were of varied opinion on whether video visits should be paid less than in-person visits and whether audio visits should be paid less than video visits, as the MedPAC staff recommended. One the one hand, commissioners recognized that the costs of delivering video and audio visits are likely lower than in-person visits. On the other hand, the costs are likely only marginally lower, and paying less for these services may disincentivize clinician adoption.
For more information regarding the MedPAC meeting, please see our Manatt Insights newsletter.
Recent State Activity Related to Audio Telehealth
North Carolina: In light of known broadband access issues in rural parts of the state, North Carolina’s Medicaid program temporarily covered several services (telephonic evaluation and management, a range of behavioral health services, perinatal care, and preventive screenings, among others) when delivered via audio during the pandemic. The program recently published a range of new permanent clinical coverage policies that provide for ongoing coverage for telephone evaluation and management services, as well as audio-only visits for certain behavioral health services.
New Hampshire: Governor Sununu enacted HB 1623 in July 2020, which amended the state’s definition of telemedicine to include audio-only services and requires Medicaid and private payers to reimburse for services delivered via all telehealth modalities, including video, audio and other electronic media, on the same basis as in-person care. In January 2021, state lawmakers opposed to the new law introduced legislation aimed at rolling back Medicaid reimbursement for audio-only service delivery.
Vermont: The state directed the Department of Financial Regulation to develop a report with recommendations for health insurance and Medicaid coverage of telephonic services. Notable recommendations from the group include:
- Requiring that audio-only health care services continue to be covered by Medicaid and commercial insurance after the PHE, but only when the service is medically necessary and clinically appropriate, and when in-person or audio-visual services are unavailable;
- Requiring informed patient consent for audio-only services;
- Requiring providers who offer audio-only services to complete training, as appropriate;
- Addressing the digital divide (issues related to broadband, technology and digital literacy); and
- Applying the same standard of practice across telehealth modalities.
Of note, the group did not come to a consensus on whether audio-only services should be reimbursed at parity with in-person services or at another rate.
Rhode Island: The Office of the Health Insurance Commissioner (OHIC) established the Telemedicine Subcommittee to develop recommendations for the future of telemedicine policies in the state. The OHIC recommended audio telehealth to be covered on a permanent basis when the services are clinically appropriate, as determined by the insurer. The group determined that behavioral health services delivered via telehealth should be reimbursed at the same rate as in-person visits, regardless of modality, but did not propose payment parity for other services. The OHIC expressed concern that restricting payment for audio services could disproportionately affect low-income populations and racial and ethnic minorities.
New York: Governor Andrew Cuomo of New York has signaled his intent to enact comprehensive telehealth reform through proposed legislation. Cuomo has proposed requiring Medicaid to cover telephonic services when medically appropriate.
Key Considerations for Policy Makers
The COVID-19 pandemic has forced policy makers to grapple with how to cover audio telehealth services. As noted above, very few states offered coverage and reimbursement for these services prior to the pandemic. While the pandemic has highlighted that telephonic services can be useful, and in some cases necessary, for connecting patients to their health care providers, there remains limited data to answer critical questions about clinical appropriateness and cost.
Policy makers are grappling with several key issues related to coverage of audio services:
- Supporting Health Equity by Increasing Access to Care. Covering audio services can support health equity efforts by increasing access to care for underserved communities and low-income individuals who do not have broadband Internet at home or access to a video-enabled device. A recent RAND study indicated that California’s Federally Qualified Health Centers (FQHCs) relied upon audio-only services heavily during the pandemic. The study noted that “while there are important concerns about the quality of audio-only visits, eliminating coverage for telephone visits could disproportionately affect underserved populations and threaten the ability of clinics to meet patient needs.”v
- Potential for Overutilization. Given the ease of audio telehealth, some policy makers are concerned that covering and reimbursing for these services may result in unnecessary overutilization, thereby driving up program costs.
- Reimbursement Rates. While the debate over payment parity for video visits continues to take shape, policy makers must now also consider how to reimburse for audio services relative to how they reimburse for video visits. Proponents of telehealth argue that reimbursing for video or audio-only visits at rates less than the equivalent in-person rates will deter clinician adoption; however, it is likely true that audio telehealth is a less costly modality than video and in-person care.
- Quality Concerns. Some policy makers worry that without a video connection and the ability to communicate via visual cues, patients will receive lower quality care than with video or in-person. More study is needed to establish which visits can safely be conducted via various telehealth and in-person.
In an effort to balance both the pros and cons of audio-only coverage in this new telehealth frontier, policy makers might consider the following approaches to permanent telehealth policy design:
- Tailoring Audio-Only Coverage Based on Clinical Appropriateness. There is no doubt that most physical health services are best delivered when a provider is able to visually assess a patient. However, states may consider narrowing their audio-only coverage to only a select set of services (e.g., evaluation and management services that don’t require a physical exam, or behavioral health counseling) that they deem can be delivered via audio-only in a clinically appropriate manner. This could allay concerns regarding quality of care, while ensuring patients have access to some services via audio-only.
- Auditing Audio-Only Claims to Prevent Overutilization. To limit potential fraud and abuse, policy makers may choose to conduct routine audits of telehealth claims to ensure that providers are not overutilizing the audio-only modality (e.g., monitor for unexpected spikes within a specific covered service, or for providers billing more claims than hours in a day).
Going forward, it will be critical to have further study and analysis of the impact of various coverage and reimbursement policies on clinical quality, access and cost in order to design policy that appropriately balances these imperatives.
NOTE: For more information on how Manatt’s Digital Health team can support you, click here.
1 Note: The topic of payment rates for different telehealth modalities, including audio-only, was discussed at the
i Velasquez, David, and Ateev Mehrotra. Health Affairs Blog. “Ensuring the Growth of Telehealth During COVID-19 Does Not Exacerbate Disparities in Care.” May 8, 2020. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/.
ii Uscher-Pines L, Sousa J, Jones M. “Telehealth Use Among Safety-Net Organizations in California During the COVID-19 Pandemic.” JAMA. February 2, 2021. Available at: https://jamanetwork.com/journals/jama/fullarticle/2776166?guestAccessKey=1cbe677e-5cda-4394-9933-078d1fcfecaf&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=020221.
iii Roberts ET, Mehrotra A. “Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine.” JAMA Intern Med. 2020;180(10):1386–1389. August 3, 2020. Available at: doi:10.1001/jamainternmed.2020.2666.
iv Watzke B, Haller E, Steinmann M, et al. “Effectiveness and cost-effectiveness of telephone-based cognitive-behavioral therapy in primary care: study protocol of TIDe – telephone intervention for depression.” BMC Psychiatry 17, 263. July 19, 2018. Available at: https://doi.org/10.1186/s12888-017-1429-5.
v Uscher-Pines L, Sousa J, Jones M. “Telehealth Use Among Safety-Net Organizations in California During the COVID-19 Pandemic.” JAMA. February 2, 2021. Available at: https://jamanetwork.com/journals/jama/fullarticle/2776166?guestAccessKey=1cbe677e-5cda-4394-9933-078d1fcfecaf&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=020221.