Telehealth reimbursement rules pit insurers against doctors

Prior to the pandemic, telehealth coverage was a wild west. Insurers were at liberty to adopt telehealth reimbursement at will, and often employers could exclude such benefits from their plans.

When the coronavirus disrupted in-person care in early 2020, the state and federal government moved quickly to create temporary rules. In Massachusetts, the governor’s emergency rules required that both MassHealth and commercial insurers provide broad coverage of telehealth visits and reimbursed them at rates equal to in-person visits. Use of the technology skyrocketed.

But insurers and providers disagreed on how to shift that temporary framework to permanent policy. Insurers said equal reimbursements were unnecessary for a digital service that could save the state money. For their part, providers said the costs of providing care hadn’t changed, and uneven reimbursement would disincentivize use.

The January 2021 legislation set the new ground floor. The law said insurers had to cover telehealth for behavioral health visits permanently at rates equal to in-person visits. For a period of two years ending in 2022, telehealth visits for primary care and chronic conditions would also be covered, under the law, at rates equal to in-person visits. After that, the reimbursement rates in these areas would be subject to negotiation between insurers and hospitals. The Division of Insurance set out to create regulations to implement the law.

More than a year later, insurers are still waiting on those regulations. A spokeswoman for the Division of Insurance did not respond to requests for comment.

In the absence of regulations, the state’s largest insurer, Blue Cross Blue Shield of Massachusetts, filed its own plan with the Division of Insurance, a policy that went into effect in April. The insurer’s policy defines behavioral health, primary care, and chronic care primarily by the type of practitioner that is providing it, rather than by the service. For providers that fall outside of the law’s “payment parity” requirements, Blue Cross will pay them 80 percent of the in-person visit. The insurer noted that, in some cases, it covers services at the in-person rate regardless of who delivers it, such as psychotherapy.

Garofalo’s services are covered for now as a primary care doctor. But after December Garofalo worries he’d be reimbursed 20 percent less than a psychiatrist would when he provides mental health care in a telehealth visit. Blue Cross Blue Shield said it had not decided on a reimbursement for primary care providers after December.

“There is no real medical rationale for why a psychiatrist should be paid at the full rate and a family medicine physician should be paid 80 percent of that rate,” said Garofalo, who is also a member of the Massachusetts Medical Society. He said on average, 15 to 25 percent of the patients he sees are seeking help for what would be considered a mental health issue, such as getting a prescription to manage anxiety or being diagnosed with ADHD.

Other providers will see more immediate differences. Some kinds of reproductive health care delivered via telehealth would be fully reimbursed if the provider were a primary care doctor, but not if the physician were an OB/GYN, said the Massachusetts Health & Hospital Association.

Adam Delmolino, director of virtual care and clinical affairs at the Massachusetts Health & Hospital Association, which represents state hospitals, said the different interpretations of the law, in the absence of state regulations, open the door for confusion for providers, the opposite of the law’s intent of streamlining telehealth delivery.

“With how busy and strained [doctors] are as we come to the end of the pandemic, they shouldn’t have to check in with every payer to see if they will be reimbursing for in-person when conducting telehealth,” Delmolino said. “This lends itself to administrative complexity. Providers need predictability when dealing with these policies.”

Blue Cross representatives defended their interpretation of the policy, which was approved by the Division of Insurance before it was put in place this month.

Matt Day, senior vice president of network payment innovation at Blue Cross Blue Shield of Massachusetts, said that the insurer’s policy goes further than the law. It requires that self-insured accounts, usually large employers that pay for their own claims, also have telehealth coverage policies. Usually, self-insured accounts are not subject to state insurance laws.

Compared to 2019 policies, Day said today’s policies by Blue Cross Blue Shield of Massachusetts were expansive.

Mike Caljouw, vice president of government and regulatory affairs at Blue Cross Blue Shield of Massachusetts, said the policy balances coverage with concerns around affordability.

“We believe our plan is consistent with that balance the Legislature placed on this topic,” he said

State Senator Cindy Friedman, who was involved in the law’s drafting and passage, agreed that affordability concerns needed to be top of mind as insurers interpreted the law. But she said the developing patchwork of policies could reverse some of the adoption of telehealth use while making health care more complex, something legislators have been actively working to reduce.

“I am concerned about it,” Friedman said. “You get into these nuances. Some people are trying to deliver care, some people are trying to save money, and some are trying to make money. That’s one of the problems with our health care system. I’m looking forward to this being resolved and resolved quickly.”

Friedman said her office was having many conversations with the division about the regulations, and that the division was working diligently on them.

For now, other insurers have not yet filed changes to their telehealth reimbursement plans, because of the continued uncertainty with the pandemic, said Lora Pellegrini, CEO of the Massachusetts Association of Health Plans, which counts 15 of the state’s largest insurers as members, although not Blue Cross. As such, other insurers are covering all telehealth services at in-person rates. Insurers are eyeing next year, when they will begin negotiating reimbursement rates for telehealth for every service except behavioral health, as a time when they could negotiate lower rates.

“Each plan will come to that with a provider individually. We do believe telehealth is here to stay and is an important tool but doesn’t replace the in-person visit,” Pellegrini said.


Jessica Bartlett can be reached at jessica.bartlett@globe.com. Follow her on Twitter @ByJessBartlett.

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