In This Public Health Emergency Update:

  • Telehealth cost-sharing and coverage changes
  • Aetna telehealth changes
  • Full FDA approval for Pfizer vaccine
  • Additional dose allowance of the COVID vaccine
  • CMS requests Medicaid claim documents be sent directly to MO HealthNet providers
  • Resumption of Targeted Probe and Educate (TPE)
  • Reminders

Telehealth Cost-sharing

In March of 2020, most commercial and Medicare payors waived cost-sharing for telehealth visits with all in-network providers. For commercial insurers, this ended in June of 2020. Medicare continued to waive cost-sharing for all providers until January 2021 when this changed to apply for only in-network telehealth visits for primary care, urgent care and behavioral health. Specialty telehealth visits are not included. Many payors continue require no out-of-pocket costs for COVID testing, and some insurers, like Humana, are covering COVID treatment-related costs through 2021.

Aetna and Telehealth

Until recently, commercials payors have continued to allow patients to see their in-network providers via telehealth, no matter the plan. However, there are now reports that this is changing. Looking at Aetna, they are no longer making allowances for telehealth when members do not have that coverage in their existing policy. These claims are rejected and charges become patient responsibility.

We anticipate other providers to follow Aetna’s lead, if they have not already. Remind your patients to stay informed of their personal coverage limitations through their insurance plans.

Full FDA Approval of Pfizer Vaccine

On August 23, 2021, the Food and Drug Administration (FDA) approved the Pfizer-BioNTech COVID-19 vaccine, for the prevention of COVID in individuals 16 years of age and older. The vaccine continues to be available under emergency use authorization (EUA) for individuals ages 12 to 15 and/or for the administration of a third dose in certain immunocompromised individuals (see booster information directly below).

COVID Vaccine Booster

On August 12, 2021, the FDA amended the EUAs for both the Pfizer and Moderna COVID-19 vaccines to allow an additional dose for certain immunocompromised people. Specifically, this refers to organ transplant recipients or those with conditions considered to have an equivalent level of immunocompromise. A third dose can be administered to qualifying individuals as early as 28 days following the two-dose regimen of the same vaccine.

While an additional dose is necessary for those who may not have had a strong enough immune response from their first two rounds, and a booster shot is available for those whose immune response may have weakened over time. The CDC has made available its recommended guidelines for booster recipients.

With regards to reimbursement, CMS has announced it will continue to provide coverage for critical COVID protection, including booster doses, without cost-sharing.

Medicaid Claims Documents

Effective August 11, 2020, CMS resumed all Payment Error Rate Measurement (PERM) engagement with providers and states previously suspended in response to the PHE. With their PERM process, the Centers for Medicare & Medicaid Services (CMS), is analyzing improper payments in Medicaid and the Children’s Health Insurance Program (CHIP).

PERM contractors will be sending records requests directly to Missouri Medicaid/CHIP providers for claims billed during 2021 state fiscal year, and federal regulations require that providers submit the applicable medical record documentation to CMS upon request. Providing medical records for Medicaid/CHIP patients does not violate HIPAA. Patient authorization is not required to respond to this request. CMS and its contractors will comply with the Privacy Act federal regulations governing the sharing and transmission of protected health information.

Resumption of Targeted Probe and Educate

CMS’s Targeted Probe and Educate (TPE) program was designed to help providers reduce claim denials and appeals with one-on-one assistance. Effective September 1, 2021, CMS has authorized WPS to resume the TPE program. They are looking for providers with high claim error rates and services that have high national error rates. Providers selected for review based on data analysis irregularities will be notified prior to the start of their TPE review.

Reminders

The Public Health Emergency (PHE) has been extended for an additional 90 days, effective on October 18, 2021 and expiring on January 16, 2022. The Biden administration continues to indicate that they will provide a 60-day notice to states prior to bringing an official end to the PHE.

As a reminder, when using audio-only codes, make note of the time spent speaking with the patient. If you utilize a program with visual capabilities (Facetime, Zoom, etc.) for telehealth visits, you just need to include the GT or 95 modifier with your regular CPT codes.

As insurance companies are continually re-evaluating their broadened COVID policies, EMB will continue to monitor these shifts to keep you informed of any critical changes. Please come to us with any questions regarding telehealth and how the ongoing PHE affects your billing.

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