What framework conditions and decision-making processes lie behind the costs and the commercial reimbursement of costs for digitally supported care? Research from the New American Medical Association (AMA) suggests that these new digital health services and tools lack a coverage agreement, inconsistent coverage policies in the commercial market, and an inconsistent level of coverage policy transparency.
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A new study1 Published by the AMA and Manatt Health, the book aimed to summarize publicly available policies from commercial health insurers for 21 unique digital medical services to better understand the existing commercial payer insurance landscape and the decision-making process behind coverage determinations.
“Achieving fair, equitable and transparent coverage and payment for digital medical services remains a challenge,” write the study’s researchers. “These issues ultimately impact the widespread adoption and accessibility of digital medical services for both patients and physicians.”
Using AMA Current Procedural Terminology (CPT) billing codes for outpatient and physician care from 16 commercial payers, researchers identified which digital health services are funded and what opportunities exist to improve digital health access.
Here are the 16 commercial payers:
- Etna
- Blue Cross Blue Shield of Illinois, Massachusetts, Michigan, North Carolina, Texas and California
- CareFirst Blue Cross Blue Shield
- Cigna
- Elevance Health
- Florida Blue
- Highmark Blue Shield
- Horizon Blue Cross Blue Shield of New Jersey
- Regency
- Tufts Health Plan
- UnitedHealth Group
The billing codes of included services were remote physiological monitoring (RPM), remote telemetric monitoring (RTM), e-consults (interprofessional telephone/Internet/electronic health record assessment by a consultant physician), and e-visits (online digital assessment and management). Service for an established patient). In addition, insurance coverage was categorized based on payer validation. The range ranged from coverage of the CPT code and coverage through restrictions and clear conditions to not coverage of the CPT code or approval of the service through telemedicine. However, the payer instructs providers to use different codes.
RPM and RTM billing codes included service initiation, device provisioning and data transfer, treatment management services, and self-measured blood pressure.
Coverage limitations and conditions included specific terms only, frequency limitations not payable today but expected to be payable from fall 2023, and temporary coverage until December 31, 2023.
The analysis found that there is no uniformity of coverage across commercial, Medicare and Medicaid insurers, with commercial insurance lagging behind Medicare and Medicaid. Although Medicare and Medicaid cover all 21 digital health services, some commercial plans imposed additional requirements beyond CPT and Medicare requirements. Some of these payers only cover codes for certain conditions, such as: E.g., heart failure, chronic obstructive pulmonary disease (COPD), COVID-19, hypertension, etc., and others have chosen not to provide coverage for a specific condition.
Further inconsistencies were identified in the rollout of digital health insurance policies across the commercial market and in the level of transparency of these insurance policies. Although most commercial insurers cover RPM, coverage is still being evaluated and is less consistent with newer digital therapies, e-consults, and e-visits. Additionally, while some payers have publicly available clinical insurance policies for telehealth services, many do not have these telehealth policies publicly available or they are outdated.
Other discrepancies noted included a time lag in determining coverage policies and limited widespread use of most new digital medical services.
Additionally, as commercial payers partner with telehealth companies to offer these services to their patients, the researchers found that these programs are often not tied to the patient’s medical care or existing primary care physician, which can create further barriers to care.
“While the United States has entered an era in which digitally assisted care is integrated into in-person care, the potential of this hybridized care model has not yet been fully realized,” said Jesse M. Ehrenfeld, MD, MPH, president of the AMA. in a statement.2 “The lack of commercial insurance coverage can be a barrier or bottleneck to affordable access to digital medical services for more than half of the U.S. population that relies on private health insurance.” Barriers to clear and consistent insurance policies must be removed for this to happen “The pace of digital health progress in medicine matches the promising potential of the technology.”
