Remote Patient Monitoring Reimbursement
Telehealth coverage is a rapidly evolving landscape, and it can be difficult to keep pace with the constant changes. The good news is that industry-wide sentiment is overwhelmingly positive towards the value that telehealth and remote patient monitoring technologies provide. The bad news is that, as usual, reimbursement lags behind innovation and can stifle adoption rates.
We have created this guide to help you navigate the payment landscape and search for potential opportunities for reimbursement. If you still have questions, or would like further assistance in determining eligibility in your area, please reach out to us at support@clarishealthcare.com.
Medicaid
The majority of states have already passed legislation mandating telehealth and remote patient monitoring coverage for Medicaid beneficiaries suffering from chronic disease. State legislators and healthcare providers agree that remote patient monitoring has demonstrated a significant impact upon patients’ abilities to self-manage their chronic conditions. These technologies are able to capture and relay biometric data that can be used by caregivers to assess, triage, and coordinate care among at-risk populations, which, in turn, substantially reduces costs associated with poor outcomes.
Laws and stipulations regarding mandated coverage will vary from state to state, so it’s important to stay up-to-date with forthcoming legislation and policy changes in your state.
For more information regarding RPM reimbursement in your state, please see our map above, as well as the Center for Connected Health Policy’s guide to State Telehealth Laws and Reimbursement Policies.
Parity Laws
Beneficiaries in states which have mandated coverage of RPM technology as part of their telehealth definition and parity laws which require that insurers provide coverage for the same telehealth benefits will be eligible to receive reimbursement for their use of RPM technology for the self-management of chronic conditions in the home.
Many states already have such coverage, and several more are expected to provide similar rulings in the next year.
Medicare
CPT Code 99091
As of Jan 1, 2018, CMS will reimburse $59 per patient per service period (30-day) for Remote Patient Monitoring services. Although CMS has imposed a number of requirements with respect to CPT Code 99091, it is important to note that Remote Patient Monitoring is NOT subject to the same restrictions that currently govern reimbursement of general telehealth services under Medicare.
Specifically, reimbursement for RPM services is not limited by geography to rural or medically underserved areas, nor is there any “originating site” restriction for RPM services. In fact, RPM services can be provided anywhere the patient is located, including at the patient’s home.
Changes to RPM Reimbursement – FY 2019
Medicare has announced that it will begin reimbursing for the collection and analysis of physiological data captured via RPM technology in FY2019.
The new codes included in the 2019 Physician Fee Schedule and Quality Payments Program are:
- CPT 99453: Remote monitoring of physiologic parameters (e.g. weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education of use of equipment.
- CPT 99454: Remote monitoring of physiologic parameters (e.g. weight, blood, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
- CPT 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.
The most notable difference between these new codes and the previous CPT 99091 is that CPT 99457 now allows RPM services to be performed not only by the physician or qualified healthcare professional but also by “clinical staff,” such as RNs and medical assistants. This should make it easier for healthcare providers to figure RPM programs into their workflow.
Value-Based Programs
Private insurers offering value-based programs will often provide reimbursement for novel technologies, such as RPM technology, that they otherwise might not provide coverage for. In other cases, providers are given an advanced payment that can be used by the care coordinator to provide services at their discretion and reimbursement is not tied to a set fee schedule.
For CMS-led value-based programs, reimbursement is tied to the Physician FFS Schedule, though providers may be able to take advantage of certain patient engagement and technology waivers for devices not covered under the fee schedule.
Some examples of value-base programs are:
Accountable Care Organizations (ACOs)
ACOs bring together different care providers, including primary care physicians, specialists, hospitals, and other health care professionals in order to better coordinate patient care. Doing so allows these organizations to operate more efficiently and manage patients’ long-term health, including chronic conditions, more effectively.
ACOs are rewarded when they meet or exceed certain benchmarks that are generally set around reducing cost while improving the standard of care. ACOs tend to be large in scale and are most effective at managing population health across entire communities or regions.
Patient-Centered Medical Homes
Patient-centered medical homes are structured in much the same was as ACOs, except patients in patient-centered medical homes have all aspects of their care organized by their single primary care physicians. The primary care physician is compensated for each patient that is under their care, as well as a share of any savings from reducing downstream costs.
Insurers offering such programs:
*This list is not intended to be exhaustive, as payers are continuously developing new value-based programs and experimenting with different models. Please contact representatives from your network if you are interested in finding out what value-based models are currently available through your insurers.
