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How value based care is changing telehealth payment models


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How value based care is changing telehealth payment models

  1. 1. Presented By: Heather Zumpano @HZumpano Aneel Irfan @Aneel_Irfan
  2. 2. Medicaid Medicare & MACRA Quality Payment Program Private Insurance Revenue Models
  3. 3. 48 states reimburse for live video 2-way communication 19 states reimburse for remote patient monitoring 12 states reimburse for store and forward 30 states reimburse for a transmission/facility fee 2 states reimburse through the Dept. of Aging Services For your state’s specific Medicaid Reimbursement Laws, visit the Center for Connected Health Policy website: Reimbursement By the Numbers: 29 states require signed informed consent prior to visit
  4. 4. 24 states cover telehealth for state employees 24 states plus D.C. cover care regardless of origin 25 states recognize home as originating site 41 states cover service state-wide 28 states don’t require a telepresenter Reimbursement By the Numbers: 15 states plus D.C. will pay any type of provider For your state’s specific Medicaid Reimbursement Laws, visit the Center for Connected Health Policy website:
  5. 5. Guidelines based on traditional care models and limited to Health Professional Shortage Areas and specific care centers (i.e. CAH, FQHC, SNF, CMHC) Legislation is making its way through Congress to expand Medicare coverage
  6. 6. Use the correct CPT/HCPCS code 2. Add the “GT” modifier to show the visit was virtual 3. The originating site uses HCPCS code Q3104 to bill a transmission/facility fee 2017 List of Services and CPT Codes
  7. 7. 1. Advanced Alternative Payment Models (APM)- Earn an incentive payment for participating in an innovative payment model 2. Merit-based Incentive Payment System (MIPS)- Earn a performance-based payment adjustment To qualify, you must bill Medicare more than $30,000 in Part B charges and provide care for more than 100 Medicare patients a year. Visit
  8. 8. 1. Accountable Care 2. Episode-Based Payment Initiatives 3. Primary Care Transformation 4. Initiatives Focused on Medicaid and CHIP Populations Source:
  9. 9. 5. Initiatives Focused on Medicaid/Medicare Enrollees 6. Initiatives to Accelerate Development and Testing of New Payment/Service Delivery Models 7. Initiatives to Speed Adoption of Best Practices Source:
  10. 10. Combination of Meaningful Use, PQRS, and the Value-Based Modifier into one performance based payment program Allows providers to select their measures, track the data and report to CMS Physicians are reimbursed per member per month or billed on a per case rate
  11. 11. CMS encourages participation in the APM and MIP programs as research methodologies to identify the future of health care payment reform If you have an idea for a payment model for either payment track, CMS wants to hear from you. Each year they post their provisions for open discussion and incorporate ideas into the Final Rule. Be the Change You Want to See!
  12. 12. Source: 34 states and DC have a Telemedicine Parity Law
  13. 13. Aetna Anthem Blue Cross/Blue Shield Cigna United Health Care
  14. 14. Institution to Institution- Payment models include a monthly contract, hybrid payment, or fee schedule menu of services and specialties. Employer Workforce- Physicians can offer employers a primary care network using on-site kiosks, mobile apps, or computers to bring medical access to their employees. Services can be paid by an employer’s self- funded health plan, out-of-pocket by an employee, per member per month, or case rate.
  15. 15. Direct-to-Consumer- Patients can pay out-of pocket or use their HSAs monthly or annually for access to these services. In many cases the virtual visit is about the same rate as a co-pay for an in-person visit. International Agreements- the large demand for U.S. doctors in other countries presents great opportunities to contract with foreign governments, NGAs, and medical practices. There are also less legal barriers to providing care in the global medical arena.
  16. 16. Thank You for Attending! Heather Zumpano @HZumpano Aneel Irfan @Aneel_Irfan