CMS to Expand Telehealth Coverage for Medicare Advantage Plans

by | Last updated Feb 8, 2024 | Published on Nov 5, 2018 | Insurance Verification and Authorizations

CMS to Expand Telehealth Coverage for Medicare Advantage Plans
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Telehealth can improve access to care. The original Medicare telehealth benefit includes restrictions on where beneficiaries receiving care via telehealth can be located. The proposed rule would allow Medicare Advantage (MA) and Part D plans to cover additional telehealth benefits starting in 2020, with which MA plans will have more flexibility than is currently available in how they pay for coverage of telehealth benefits. Physicians providing telehealth services can consider outsourcing medical billing tasks to ensure appropriate reimbursement. According to the CMS, Medicare beneficiaries are eligible for telehealth services, only if they are presented from originating sites approved by the agency such as –

  • The offices of physicians or practitioners
  • Hospitals
  • Critical Access Hospitals (CAHs)
  • Rural Health Clinics
  • Federally Qualified Health Centers
  • Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
  • Skilled Nursing Facilities (SNFs) and
  • Community Mental Health Centers (CMHCs)

Earlier, telehealth services were covered only for rural residents, who may need to travel considerable distances to receive in-person care. With its consideration to expand telehealth coverage, CMS believes that the additional telehealth benefits in MA will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits. The proposed rule would give MA plans more flexibility to offer telehealth benefits to all their enrollees, whether they live in rural or urban areas.

The proposal would also allow Medicare Advantage enrollees to receive telehealth service from places including their homes, rather than going to a health care facility. CMS Administrator Seema Verma says, “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote more access to care in a more convenient and cost-effective manner for patients.”

It is recommended that in the Medicare Open Enrollment for 2019 that is currently underway and runs through December 7, 2018, seniors can review their coverage options and decide how they would like to receive their Medicare benefits in 2019. With this proposed change, more payers are also expected to provide MA, thus expanding access to telehealth services. The rule would also help CMS recover improper payments made to Medicare Advantage organizations.

As these plans are reimbursed based on each member’s sickness level, the CMS uses its Risk Adjustment Data Validation (RADV) audits to make sure that the data submitted by insurers matches the patient’s diagnoses. According to the report from Fierce Healthcare, these proposed changes to MA audits could put insurers on the hook for billions. Insurance companies can consider comprehensive RADV audit services from professional medical billing companies to establish whether the diagnosis codes submitted can be validated by medical record documentation. CMS expects that, if finalized, these proposed changes would result in an estimated $4.5 billion savings to the Medicare Trust Funds over a ten year period, largely from the recovery of improper payments to Medicare Advantage plans through contract-level RADV audits.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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