Telemental health (or telebehavioral health, Telepsychiatry) is the use of telecommunications technology to provide behavioral health services. Examples of telemental health services include providing health workers in remote areas with continuing education on mental health topics, videoconferencing consultations on routine and crisis behavioral health cases using a "virtual" case management team, and providing traditional psychotherapy and psychiatric consultation services through real-time videoconferencing.
Telebehavioral health services can be offered through intermediary companies that partner with facilities to increase care capacities, or by individual providers or provider groups. There are several HIPPA-compliant telebehavioral health platforms but there are many barriers in place to ensure that online services are offered at the same level of security and validity as in-person services.
While telecommunications have been used for decades to provide some behavioral health services (usually for emergencies or for experimental purposes), it was only in the 1990s that telemental health care services truly came into their own. Despite the early success of telemental health care services however, wide-scale implementation remains dependent on policy and funding initiatives. However, with many states recently passing or voting on telemedicine parity laws, the outlook for a future of widespread telemental health services remains positive.
Reimbursement for Telebehavioral Health in the United States
Reimbursement by Medicare
Reimbursement for Medicare-covered services must satisfy federal requirements of efficiency, economy and quality of care. Since 1999, Medicare and Medicaid reimbursement for all kinds of telehealth services have expanded, requirements of providers have been reduced, and grants have been given to support telehealth program adoption.
For 2014, the Center for Medicare (CMS) services does cover telemedicine services, including telebehavioral health in many areas. Services covered by Medicare must fall into either Category 1 or Category 2. As of now, these categories are defined as such:
- Category 1: Services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the list of telehealth services. The request is evaluated based on the similarities between the services already eligible for reimbursement, and that of the requested service.
- Category 2: Services that are not similar to the current list of telehealth services. The assessment will be based on whether the service is accurately described by the corresponding code when delivered via telehealth, and whether the use of a
telecommunications system to deliver the services produces a demonstrated clinical benefit to the patient. Supporting documentation should be included.
Medicare Telehealth Coverage Areas
There are several conditions to Medicare telehealth coverage. The first being that the consumer, or individual receiving telehealth services must be physically located in an “originating site” that is eligible for Medicare coverage.
Those sites include:
- A Health Professional Shortage Area (HSPA).
- Outside a Metropolitan Statistical Area (MSA)
- Within a MSA rural census tract determined by HHS’s Office of Rural Health Policy.
- Rural areas as defined by the department of health and human services (HRSA)
State specific Medicare Reimbursement
States have the option/flexibility to determine whether or not to cover telemedicine under the Medicaid assistance program. They may also decide:
- What types of telemedicine to cover
- Where telemedicine will be covered throughout the state
- How telemedicine services are to be covered/reimbursed
- What types of providers/practitioners can be covered/reimbursed
- How much to reimburse for telemedicine services (as long as payments do not exceed Federal Upper Limits)
Individual states are encouraged to use flexibility granted by federal law to create payment methodologies that incorporate telemedicine technology. For example, sates can reimburse the practitioner at the distant site an reimburse a facility fee to the originating site. States can also reimburse support costs like technical support, transmissions charges, and equipment. Add-on costs like those can be incorporated into the fee-for services rate or separately reimbursed as an administrative cost by the state.
If a state decides to cover telemedicine, but not to cover certain areas or certain practitioners, then the state must be responsible for assuring access and covering face to face visits by recognized providers in those parts of the state where telemedicine is not available.
42 states now provide some form of Medicaid reimbursement for telehealth services. For a complete list, visit the NCSL website. There are also entities that participate in a federal telemedicine demonstration project approved by or receiving funding from the Secretary of the Department of Health and Human Services that qualify as originating sites regardless of their location. These include:
- The offices of physicians or practitioners
- Critical Access Hospitals (CAH)
- Rural health clinics (RHC)
- A skilled nursing facility
- A hospital-based or critical access hospital-based dialysis facility
- A community mental health center (CMHC)
- Federally Qualified Health Centers (FQHC)
All telemedicine encounters must take place in real-time, face-to-face interactions using audio and video equipment at both consumers’ and physicians’ locations.
Reimbursement by Private Payor
Currently, the following states have a previously enacted Legislated Mandate for Private Coverage:
- District of Columbia
- New Hampshire
- New Mexico
There are usually two types of events that are billed with a telepsychiatry visit: a provider fee and a facility fee to help offset costs. Telepsychiatry providers can panel with up to 2 major commercial payers as well as Medicare and Medicaid, if beneficial to the program.
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