Goldstein: Will Expansion of Telehealth Lead to More Conditional Payments?

Thursday, April 2, 2020 | 0

In 2019, Medicare started covering some virtual care services. The services included brief communications and Virtual Check-Ins (short patient-initiated communications with a health care practitioner) along with e-visits (non-face-to-face patient-initiated communications through an online patient portal).

Jean S. Goldstein

However, telehealth services have generally not been covered. Historically, for telehealth services to be covered, certain circumstances would need to apply. For example, if the beneficiary lived in a rural area, and even then, travel to a local medical facility for telehealth services from a doctor in another remote location was often required, and the beneficiary generally could not get telehealth services in the home.

That was until earlier this month when the Centers for Medicare & Medicaid Services (CMS) lifted the restrictions and announced that it is broadening access to Medicare telehealth services in an effort to ensure that beneficiaries can get a wider range of services from medical providers without traveling to a health care facility.

The expanded coverage allows for telehealth services, regardless of where the beneficiary resides, and in any health care facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from a beneficiary’s home. The specific set of services covered under Medicare’s broadened coverage includes evaluations and management visits (common office visits), mental health counseling and preventive health screenings, without regard to a beneficiary’s diagnosis. 

Lifting the prior coverage restrictions is certainly a justified modification, with growing concerns of transmission of the coronavirus to beneficiaries. Nonetheless, from a claims management perspective, primary payers may need to be on alert for conditional payments that could result from broadened coverage.

A conditional payment occurs when Medicare makes a payment for services another payer may be responsible for, or in instances where the primary payer does not pay promptly. If Medicare beneficiaries are now seeing physicians, nurse practitioners and clinical psychologists for routine visits through telehealth, there is a possibility that conditional payments will be made on a claim or body part for which a primary payer is responsible.

Moreover, given that many carriers and law firms have moved to remote work, there may be considerable delays in obtaining billing invoices affiliated with telehealth services and conditional payments. Therefore, during this time as many payers are navigating uncharted waters, we offer the following tips: 

Create an open dialogue now between the parties to coordinate and identify treatment in the coming weeks. Do not assume that beneficiaries are not treating because bills have not been received. Ask questions of beneficiaries as to whether they are still treating or have utilized telehealth services.

Review your processes on how to timely handle conditional payments, Medicare Advantage Plan recoveries and other liens. Remember that conditional payments are not just made by Medicare, but also can be made by Medicare Advantage Plans, Group Health Plans, Medicaid and the Department of Veterans Affairs. Also, it is important to understand that your own internal workflows may have shifted during this unprecedented time.

It is beneficial to review whether conditional payment notices and demands are being received and documented in the same manner, through the same mail collection processes. Revisiting these workflows may make the difference as to whether penalties and interest associated with conditional payments are incurred. 

With workflows having changed quite significantly over the last several weeks, and the possibility of increased recovery efforts on the horizon, this may be an opportune time to consider designating a recovery agent. A recovery agent is an entity or organization that will receive, directly from the CMS contractor, copies of all conditional payment recovery correspondence associated with an applicable plan. 

Designating a recovery agent ensures that a named agent will receive all conditional payment recovery correspondence automatically and therefore be able to timely and efficiently respond to all recovery efforts within the required time frames, prior to claims being entered into the demand status.

Continue to diligently review, negotiate and resolve all conditional payments. Of significant note, in a recent teleconference CMS addressed specific challenges with the “grouper algorithm,” which is used to identify Medicare payments that are related to a case or condition for which a primary payer is responsible. CMS acknowledged that the algorithm has in many instances grouped unrelated charges and attributed them as conditional payments for which reimbursement was requested from a primary payer.

While CMS also indicated that an outside contractor is reviewing and addressing the current challenges associated with the algorithm, it is important to consider the possible impact of telehealth coverage being expanded. This expansion may result in additional unrelated conditional payments being identified under the grouper algorithm as beneficiaries call upon more service providers virtually. Therefore, it is more important than ever to be diligent in reviewing and disputing conditional payments.

While telehealth is providing greater access and care to beneficiaries during this challenging time, primary payers should nonetheless ensure that proactive practices to address conditional payments are in place to continue to best position claims for resolution.

Jean S. Goldstein is senior legal counsel for Medval. This post from the Medval blog is republished with permission.