Telehealth reimbursement rules pit insurers against doctors

Prior to the pandemic, telehealth coverage was a wild west. Insurers were at liberty to adopt telehealth reimbursement at will, and often employers could exclude such benefits from their plans.

When the coronavirus disrupted in-person care in early 2020, the state and federal government moved quickly to create temporary rules. In Massachusetts, the governor’s emergency rules required that both MassHealth and commercial insurers provide broad coverage of telehealth visits and reimburse them at rates equal to in-person visits. Use of the technology skyrocketed.

But insurers and providers disagreed on how to shift that temporary framework to permanent policy. Insurers said equal reimbursements were unnecessary for a digital service that could save the state money. For their part, providers said the costs of providing care hadn’t changed, and uneven reimbursement would disincentivize use.

The January 2021 legislation set the new ground floor. The law said insurers had to cover telehealth for behavioral health visits permanently at rates equal to in-person visits. For a period of two years ending in 2022, telehealth visits for primary care and chronic conditions would also be covered, under the law, at rates equal to in-person visits. After that, the reimbursement rates in these areas would be subject to negotiation between insurers and hospitals. The Division of Insurance set out to create regulations to implement the law.

More than a year later, insurers are still waiting on those regulations. A spokeswoman for the Division of Insurance did not respond to requests for comment.

In the absence of regulations, the state’s largest insurer, Blue Cross Blue Shield of Massachusetts, filed its own plan with the Division of Insurance, a policy that went into effect in April. The insurer’s policy defines behavioral health, primary care, and chronic care primarily by the type of practitioner that is providing it, rather than by the service. For providers that fall outside of the law’s “payment parity” requirements, Blue Cross will pay them 80 percent of the in-person visit. The insurer noted that, in some cases, it covers services at the in-person rate regardless of who delivers it, such as psychotherapy.

Garofalo’s services are covered for now as a primary care doctor. But after December Garofalo worries he’d be reimbursed 20 percent less than a psychiatrist would when he provides mental health care in a telehealth visit. Blue Cross Blue Shield said it had not decided on a reimbursement for primary care providers after December.

“There is no real medical rationale for why a psychiatrist should be paid at the full rate and a family medicine physician should be paid 80 percent of that rate,” said Garofalo, who is also a member of the Massachusetts Medical Society. He said on average, 15 to 25 percent of the patients he sees are seeking help for what would be considered a mental health issue, such as getting a prescription to manage anxiety or being diagnosed with ADHD.

Other providers will see more immediate differences. Some kinds of reproductive health care delivered via telehealth would be fully reimbursed if the provider were a…