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.

Proposed Changes to RPM Reimbursement – FY 2019

 

Medicare is expected to begin reimbursing for the collection and analysis of physiological data captured via RPM technology in FY2019.

 

During this year’s request for comments, requestors proposed to add the following “Chronic Care Remote Physiologic Monitoring” codes to the list of Medicare services for 2019:

 

  1. CPT 990X0 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education of use of equipment);
  2. CPT 990X1 (Remote monitoring of physiologic parameter(s) (eg, weight, blood, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days); and
  3. CPT 994X9 (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).

 

It is important to note that these codes have not yet been finalized by CMS, and there is currently no proposed fee schedule associated with these changes. CMS is expected to provide a final ruling in November 2018. If approved, the codes would go into effect January 1, 2019.

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.

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