TECH- CMS Improves Medicaid Reimbursement for Digital Health Consults

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[MM Curator Summary]: Now specialists can bill for telehealth so we can stop gaming what the PCPs are getting paid to cover the specialists costs.


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The Centers for Medicare & Medicaid Services has issued guidance changing Medicaid and CHIP coverage for eConsults, or provider-to-provider specialty consults conducted via digital health or telehealth. The  ruling could expand the service, which helps primary care providers keep more of their patients and boosts access to care for underserved patients.


The Centers for Medicare & Medicaid Services has issued new guidance on Medicaid and CHIP coverage for eConsults, or interprofessional consultations between a primary care provider and a specialist on treatment for a specific patient.

Under the new guidance, specialists are able to bill Medicaid for eConsults rather than primary care providers, who would often have to bill higher rates so that they could reimburse specialists for their services.

The platform is popular with primary care providers who want to keep more of their patients and specialists who want to expand their reach, while it improves access to care for underserved populations who can’t afford or won;t travel to see a specialist.

Federal officials have expanded coverage for specialty consults between care providers via digital health for Medicaid and Children’s Health Insurance Program (CHIP) members.

In guidance issued earlier this month, the Centers for Medicare & Medicaid Services (CMS) announced that interprofessional consultations, or instances when a care provider seeks the advice of a specialist for a patient’s treatment, via eConsults can be covered by state Medicaid or CHIP programs even when the patient is not present, as long as the consult is focused on that patient.

eConsults are clinical consults usually conducted via telemedicine (including the telephone) or digital health. They enable primary care providers to expand care management options for their own patients without having to send those patients off to a specialist. And they improve access to care for patients who might not want to travel to see a specialist due to a variety of reasons, including distance and cost.

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Alongside helping primary care providers retain more of their patients, the platform is popular with federally qualified health centers (FQHCs) and community health centers who treat underserved populations and in rural areas where access to specialists is scarce. It also helps specialists expand their reach and treat more patients in need of their services.

“Timely access to specialty providers can improve the quality of care and treatment outcomes for both physical and behavioral health,” CMS wrote in its guidance. “While access to specialty care has been a challenge across a range of specialties, access to specialty care for mental health and substance use disorders has been a particular challenge.”

The ruling changes the payment model so that the consulting provider, or the specialist, can bill for the treatment. Previously, CMS allowed the treating provider to bill Medicaid, which in many case forced the program to pay higher rates to the treating provider so that he/she could reimburse the specialist for consulting services.

To qualify eConsult coverage, both care providers must be enrolled in the Medicaid program in the state where the patient is located, though the consultant can be located in another state.

“Given the potential for improving access to specialty care, a number of states have obtained authority through state legislation for or expressed interest in covering eConsults,” the Los Angeles-based Manatt, Phelps & Phelps law firm wrote in a recent blog. “States that choose to cover eConsult codes must submit a state plan amendment to CMS to add a payment methodology for the qualifying service, and should consider broadly communicating any related policy changes to their enrolled provider community.”