CMS Proposes Permanent Payment for Telehealth Services Allowed During Pandemic

The federal government is proposing to permanently allow payment under the Medicare program for “audio-only” mental health services for patients who do not have or do not wish to use video technology. These services have been temporarily reimbursed as part of the government’s response to the COVID-19 public health emergency.

The proposed rule also would retain other temporarily reimbursed telehealth services through 2023 to provide more data for determining whether those services should be permanently added to the list of covered Medicare services.

The recommended changes are part of the proposed rule for the 2022 Physician Fee Schedule by the Centers for Medicare and Medicaid Services (CMS). A final rule will be issued in November.

“Audio-only services have been a lifeline for patients for whom it is the only option when seeking mental health and substance use disorder treatment,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a September 13 letter to CMS Administrator Chiquita Brooks-LaSure. “Patients who cannot interact with their physician via a live, synchronous audio-video connection may need to rely on audio-only care for myriad reasons: They may lack access to sufficient broadband internet or access to the technology itself (they may not own a smartphone, tablet, or PC); their diagnosis may preclude using such technology; or they may not consent to being seen via video.”

He added, “We appreciate [that] CMS is proposing to make permanent—or otherwise continue to temporarily extend and evaluate—many of the telehealth provisions that clinicians and patients have relied on over the course of the public health emergency.”

Coverage of audio-only services would be restricted to clinicians who have capability to provide two-way audiovisual services and who have seen the patient in person at least once in the previous six months. In comments to CMS submitted on Monday, September 13, APA urged CMS to waive the six-month in-person requirement, emphasizing that the need for an in-person visit should be at the clinician’s discretion.

“APA is concerned about any requirement for a patient to be seen in person by a practitioner in order to be eligible for any telehealth encounter, regardless of whether the telehealth encounter is conducted via synchronous video or via audio only,” Levin wrote. “Requiring an initial or subsequent in-person visit for a patient to qualify for a telehealth encounter of any modality will be a barrier to care. Presently, there does not appear to be concrete evidence as to the value or necessity of requiring an in-person visit prior to engaging in [telehealth]. In fact, emerging evidence suggests that implementing requirements such as these may possibly dilute the benefits of easily accessed telehealth, including audio-only care.”

He cited a recent survey conducted by the California Healthcare Foundation revealing that 38% of respondents had participated in a phone visit, and 72% said they were just as or more satisfied with their phone visit compared with their last in-person visit. Moreover, the survey found high utilization of, and satisfaction with, phone visits specifically among those with low incomes and among people of color, who already face significant barriers to traditional and telehealth care.

The fee schedule also includes changes to the physician payment formula. Importantly, CMS is proposing a reduction to the “conversion factor” used in the formula, which is likely to result in an overall reduction in physician payment. The change is partly the result of a budget neutrality adjustment that requires improvements in payment for Evaluation and Management Services last year to be offset in 2022 to maintain budget neutrality.

According to an AMA analysis of the impact of the proposed formula changes on different specialties, psychiatry would experience an overall reduction in payment of 3.1%; how individual practices will be affected would depend on practice and billing patterns.

In the letter to CMS, Levin urged CMS and the Department of Health and Human Services to work together with Congress to waive the budget neutrality adjustment set to go into place for 2022. “The reduction in the Medicare conversion factor will have a significant financial impact on psychiatrists who treat Medicare patients and comes at a time when practices have already experienced financial losses due to the COVID-19 public health emergency,” Levin wrote. “Payment cuts will only further compound the growing access problem for patients with mental health and/or substance use disorders.”

Also affecting physician payment are proposed changes to the Relative Value Units for clinical practice expenses, reflecting market changes in labor costs. These changes would have an especially adverse effect on payment for psychiatric services provided as part of collaborative care (99493, subsequent psychiatric collaborative care services).

“This reduction is not insignificant for those primary care practices that have implemented this evidence-based model of care, particularly considering the frequency with which this code is billed,” Levin wrote to CMS. “With the significant increase in need for services, now is not the time to create barriers that impact access to treatment for mental health and substance use disorders. We want to continue to encourage primary care practices to adopt the collaborative care model, which has been shown to increase access to effective care and reduce overall healthcare costs.”

He added, “We strongly encourage CMS to update the clinical labor inputs on a more frequent basis to mitigate the impact the changes have on the overall fee schedule pricing. And we urge CMS to call on Congress to provide a positive update to the Medicare conversion factor for 2022 and all subsequent years to mitigate the negative impact of these changes.” ■