More on Reimbursement

Eliminating audio-only telehealth coverage could put safety net clinics at risk

CMS has signaled that it may stop reimbursing for audio-only visits after the public health emergency.

Mallory Hackett, Associate Editor

While the increased use of telehealth during the pandemic allowed many patients to maintain access to care, reimbursement for a large portion of these visits may end with the public health emergency, creating challenges for low-income patients who rely on such services, according to a new study from RAND.

The study looked at data from billable outpatient primary care and behavioral health visits at 41 federally qualified health centers that operated at 534 locations in California from February 2019 to August 2020.

During the pandemic, the FQHCs experienced a rapid increase in telehealth usage as the clinics substituted in-person care for video and telephone visits.

For primary care visits, 48.1% occurred in person, 48.5% via telephone and 3.4% via video. Comparatively, for behavioral health visits, 22.8% occurred in person, 63.3% via telephone and 13.9% via video.

Telephone visits peaked in April 2020, comprising 65.4% of primary care visits and 71.6% of behavioral health visits, according to the study.


The Centers for Medicare and Medicaid Services defines telemedicine as "the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment."

Prior to the pandemic, CMS only reimbursed for telehealth services if both audio and video were used. But with the onset of COVID-19, the agency issued temporary flexibilities for providers to get reimbursed for both video and audio-only telehealth services.

These flexibilities allowed millions of vulnerable patients to continue to receive care during the pandemic – especially those who received care at an FQHC, which provides healthcare services to people of all ages, regardless of their ability to pay or whether they have health insurance.

"Over 3 million beneficiaries have received telehealth services via traditional telephone," said former CMS Administrator Seema Verma in a Health Affairs blog. "That means nearly one-third of beneficiaries that received a telemedicine service did so using audio-only telephone technology."

Despite that a significant portion of telehealth visits during the pandemic were conducted over the phone, CMS has signaled that it may stop reimbursing for audio-only visits when the public health emergency ends.

"While we are not proposing to continue to recognize these codes for payment under the PFS in the absence of the PHE for the COVID-19 pandemic, the need for audio-only interactions could remain as beneficiaries continue to try to avoid sources of potential infection, such as a doctor's office," the agency said in its 2021 Physician Fee Schedule fact sheet.

Eliminating coverage for audio-only telemedicine visits would disproportionately impact underserved communities that may face barriers to accessing video technology, according to Lori Uscher-Pines, the study's lead author and a senior policy researcher at RAND.

"Lower-income patients may face unique barriers to accessing video visits, while federally qualified health centers may lack resources to develop the necessary infrastructure to conduct video telehealth," she said. "These are important considerations for policymakers if telehealth continues to be widely embraced in the future."


At the end of 2020, Congressmen Jason Smith (R-Mo.) and Tony Cardenas (D-Calif.) introduced the Permanency for Audio-Only Telehealth Act, which would require CMS to continue reimbursing providers for audio-only telehealth, even after the public health emergency ends.

The American Psychological Association is one of many organizations that support the bill.

"Allowing patients to receive mental health services by audio-only telephone is a matter of health equity for underserved populations, and APA applauds this important equalizer," said APA CEO Arthur C. Evans Jr., PhD. "This bill will allow patients to receive services at home no matter where they live − whether in rural, urban or suburban communities."

Even without the bill, HHS expects to extend the public health emergency through the end of 2021, according to a letter it recently sent to governors.

Twitter: @HackettMallory
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