3 Simple Tips For Getting Telehealth Reimbursement from Private Payers

Telehealth reimbursement from private payers

Telehealth lawyer Nate Lacktman recommends that when negotiating a telehealth reimbursement contract from private payers, make sure to use the language of payers (e.g. member vs. patients), and to have a plan ready for showing them how telemedicine will benefit the payers such as by saving money or having healthier members.

Here are 3 recommendations from #pinksocks telehealth lawyer, Nate Lacktman (@Lacktman). These are taken from our telehealth video podcast series Telehealth Failures & Secrets To Success. You can watch the full episode here of Demystifying the Telemedicine Triple Threat: Reimbursements, Licensure, & HIPAA

  1. Find out what the private payer’s telehealth policies are

  2. Many of these telehealth policies are only two to three pages long, but they are often only available if you’re an in-network provider and you log into their password-secured portal.

    You may find that it’s broad. You may also find that it’s quite narrow, sometimes narrower than the law requires. In this case, you should take every effort to reach out proactively to those various payers.

    You could make the case to say, “Look, I’m not asking you to change your policy plan-wide, but for our particular agreement, let’s talk about having an addendum, a one-page amendment for telehealth-based services,” and our clients have been pretty successful on that.

  3. Put yourself in the insurance plan’s shoes

  4. Use payer language instead of physician language when negotiating.

    So many providers tend to take a myopic view and say, “These are my patients in my care and I demand and deserve to get paid by some unknown amorphous entity for that” without regard to how much the patient may pay in premiums or what benefit policy they selected for the plan’s own obligation.

    Realize that plans are focused on the obligation they owe to their members, their enrollees rather than the providers. The members are the ones who have a contract with the plan and say, “I will pay you $1,000 a month premium, and in return, you will arrange for the services.”

    So plans have to provide quality and access. Providers are merely a tool through which the plan fulfils its obligations to its members, just like you could say telemedicine is a tool through which you provide your care.

    And so the providers that we work with, that put themselves in their shoes of the plan and use the language of the plan — are much more successful.

    Instead of “reimbursements”, they use the parlance of “medical spend”, which is plan language; instead of “patients”, they use words like “members”.

  5. Collaborate with the Private Payer

  6. Set up a phone call or a meeting with your insurance, and talk about what you want to do and what you want to achieve, why you wanna achieve it. Then ultimately you lawyer it and paper it in an amendment to your participation agreement.

    And let’s say, you have it in effect for a year. You add a GT modifier, a 95 modifier. You track the utilization in the medical spend, and if a plan likes it, after a year they can continue, and if they don’t, well then they have the ability to terminate.

    In most participation agreements, a health plan can terminate it without cause in a 60-day notice. This shows you how singularly dependent many providers are on these third-party payers, and they don’t realize how much they’re at the mercy of the payers sometimes, on how these contracts are structured. So it would behove you, any of our providers, and the payers, to try to work arm-in-arm and collaborate.

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