This article is based on the 2017 Telehealth Failures & Secrets To Success (TFSS) conference talk Telehealth Reimbursement Models for Non-medical Services given by Brenda Schmidt. You can see all speakers and talks from the conference here)
“How will I get reimbursed?” is always one of the first questions people have when starting to do telehealth and telemedicine.
Good news is the number of states and private payers covering telehealth are growing each year. Bad news is with all the different rules and restrictions, it’s still a jungle out there when it comes to actually getting paid.
Telehealth reimbursement isn’t just for clinical telehealth services
While this may be changing with the push from fee-for-service to value-based care, this is no reason to sit around waiting for telemedicine reimbursement rules to change. After all, medical reimbursements aren’t the only way to get paid for providing telehealth services. If you stop to think about the range of services telehealth can actually cover – both clinical and non-medical – there’s a lot of money left on the table.
Solera – A unique approach to telemedicine reimbursement
Brenda Schmidt, CEO and founder of Solera Health preventative benefits management, is one of the those people finding creative ways to get providers reimbursed for telemedicine. During her 2017 Telehealth Failures & Secrets To Success talk, she discussed how Solera has been exploring an alternative telemedicine reimbursement model through its benefits “matchmaking platform.”
The platform connects patients to a single network of local and online providers of non-medical prevention, coping and social support services. It then matches patients and providers based on their needs and preferences. In this model, Solera submits and collects medical reimbursement claims for its members and then pays providers for services rendered regardless of whether it’s a clinical or non-medical service.
Yup – that’s right. Because Solera rather than a payer is the one paying providers, it is not bound by all those tedious telemedicine reimbursement tethers such as originating sites, rural designation, etc. Providers can get full payment for their services whether it’s clinical, non-medical (group exercise program, wellness coaching), or via telemedicine, mobile app or in-person. The only catch is that the patient’s health has to improve.
Value-based care makes possible non-medical reimbursements
So how does Solera do this? It contracts with health plans to offer prevention programs and services as a covered medical benefit for their members. It then uses a value-based or pay-for-performance (P4P) model that is measured by standard milestone-based quality metrics and paid via medical claims.
Reimbursement is determined by a set number of months a patient stays engaged in the program as well as the percentage of improvement made since s/he first signed up (based on the performance metrics set at the beginning of the program).
This is also why the service isn’t limited to a single modality, but encourages various modalities – digital apps, exercise programs, dietician visits, etc. – to fit what works best for the patient.
Alternative models of telehealth reimbursement is good for patient and providers
While reimbursement policies for telehealth services are evolving to better address the need for more effective delivery of healthcare services, we still need to be exploring other reimbursement models in the meantime. Alternative models such as P4P for non-medical services and resources not only promotes better payer, patient and health provider relationships. It also results in improved patient health and creates sustainable revenue for health providers.