The Centres for Medicare & Medicaid Services (CMS) recently confirmed that it will make several major changes to telehealth coverage in the United States.
They plan to go back to the rules that were in place on telehealth coverage before the COVID-19 pandemic, which is a blow for people who have relied on remote care since 2020.
The decision was announced in CMS’s MLN Connects Bulletin and will impact how providers deliver care, bill for services and communicate with their patients.
The latest development is a significant step backwards for many patients, especially senior citizens who have found it easier to get by with telehealth services.
Unless Congress steps in, Medicare will no longer reimburse providers for telehealth visits delivered to patients in their homes or outside rural areas.
The rules do not currently apply to behavioural and mental health services. However, hospice recertifications must return to face-to-face appointments.
Some Medicare benefits that require telehealth documentation could also be at risk if the necessary visits do not meet the geographic and site-of-service criteria.
CMS Implements Temporary Claims Hold
The government shutdown has sent the US healthcare sector into panic mode, with different departments scrambling to adapt to the sudden change.
CMS has instructed its Medicare Administrative Contractors (MACs) to place a temporary hold on claims affected by the fiscal 2025 expiration date.
The delay is standard practice and could last up to ten business days, but it will keep them from reprocessing large volumes of claims if Congress decides to take retroactive measures.
The temporary delay will not stop providers from submitting claims, but they will not get a response until the hold is lifted.
CMS officials say that, under normal conditions, the delay should not cause much trouble due to the standard 14-day payment floor for electronic claims.
However, if the shutdown is not reversed in the coming days, contractors could run out of funds, which would also affect clinics and independent practitioners.
CMS has encouraged healthcare professionals who are still providing services that are not reimbursed by Medicare to issue an Advance Beneficiary Notice of Noncoverage (ABN), pending a response from Congress. That will ensure patients are informed about potential costs beforehand.
The agency also made it clear that occupational therapists, physical therapists, speech-language pathologists and audiologists will no longer be reimbursed for telehealth visits under the reinstated rules.
How the US Could Learn from the Telehealth Model in Australia
Australia has taken a more unified approach to telehealth that the US can learn from.
Their telehealth model operates under universal federal laws through Medicare, making sure that patients have access to a wide range of services regardless of where they are located.
By streamlining the sector, Australia does not have to deal with administrative issues, and each state can tap into telehealth innovation at any time. US telehealth providers should take pointers from their counterparts in Australia, such as Qoctor.
Frequently praised for its accessibility and affordability in a comprehensive Qoctor review by Medicompare, the platform is one of the most popular telehealth services in Australia.
Qoctor offers virtual general practitioner (GP) services, mental health plans and repeat prescriptions. Most of its services are bulk billed where eligible under Medicare, making virtual care simple, transparent and affordable for Australians.
The US’ Fragmented Telehealth Landscape Comes Back to Haunt Them
The telehealth landscape in the US is too fragmented. The fact that coverage and reimbursement vary by payer has created an imbalanced system in which access to care depends more on a patient’s insurance plan than on their medical needs.
Healthcare providers who are part of a Medicare Shared Savings Program (MSSP) Accountable Care Organisation (ACOs) still have more freedom in how they can deliver and bill for telehealth services.
These ACOs are allowed to keep providing and billing Medicare for telehealth services to eligible beneficiaries even though other providers have lost some of those privileges after the pandemic-era telehealth rules expired.
They are not restricted by location and can also bill for services provided in a patient’s home. They’re backed by the Bipartisan Budget Act of 2018 and can enjoy those privileges until the end of the year.
Meanwhile, Medicare Advantage plans can still offer telehealth as part of their Part B benefits. Because these plans operate under different administrative rules than fee-for-service (FFS) Medicare, they are not automatically bound by the rollback.
However, providers must review each plan’s coverage to determine what they can reimburse.
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