On March 17, 2020, in response to the COVID-19 emergency, Medicare announced that it will reimburse physicians and other certain healthcare providers for telehealth service visits at the same amount as in-person visits regardless of where the patient is located. While the restrictions for telehealth services offered by fee-for-service providers have been relaxed, geographic and site restrictions for telehealth services provided by rural health clinics still apply.
Under 42 CFR §405.2463, rural health clinics may only bill for visits that are defined as face-to-face encounters between a rural health clinic patient and a rural health clinic practitioner. Rural health clinics are prevented from offering telehealth services to Medicare patients in their homes because they do not contain a physical face-to face encounter.
Rural health clinics will not be paid by Medicare unless the patient and provider physically meet in the office. Providers in rural health clinics should not bill telehealth services through the physician fee schedule to Medicare Part B due to potential commingling liability. CMS guidance in the Medicare Benefit Policy Manual Chapter 13 states:
- Commingling refers to the sharing of rural health clinic (RHC) or federally qualified health clinic (FQHC) space, staff (employed or contracted), supplies, equipment, and/or other resources with an onsite Medicare Part B or Medicaid fee for-service practice operated by the same RHC or FQHC physician(s) and/or non-physician(s)practitioners. Commingling is prohibited in order to prevent:
- Duplicate Medicare or Medicaid reimbursement (including situations where the RHC or FQHC is unable to distinguish its actual costs from those that are reimbursed on a fee for-service basis), or
- Selectively choosing a higher or lower reimbursement rate for the services. RHC and FQHC practitioners may not furnish or separately bill for RHC or FQHC covered professional services as a Part B provider in the RHC or FQHC, or in an area outside of the certified RHC or FQHC space such as a treatment room adjacent to the RHC or FQHC, during RHC or FQHC hours of operation.
- If an RHC or FQHC practitioner furnishes an RHC or FQHC service at the RHC or FQHC during RHC or FQHC hours, the service must be billed as an RHC or FQHC service. The service cannot be carved out of the cost report and billed to Part B.
The National Association of Rural Health Clinics (NARHC) has requested HHS and CMS remove the physical, face-to face requirements from the definition of a rural health clinic visits so rural health providers may provide and bill for telehealth services in the same manner as fee-for-service provider. We are monitoring the government’s response on this issue and will provide updates as quickly as possible.
State Medicaid Agencies
A number of state Medicaid agencies have agreed to expand the use of telehealth and pay for non-emergent E&M services provided by rural health clinics. Below is information pertaining to Louisiana, Mississippi, and Tennessee. We are monitoring each state agency’s response on this issue and will continue to provide updates.
Louisiana Medicaid, including all Healthy Louisiana MCOS, currently has no formal limitation on the originating site for telehealth services. Expansion of coverage for rural health clinics as distant site providers does not appear to be in effect. On March 21, 2020, the Louisiana Department of Health directed all healthcare providers to transition all in-person healthcare services to a telehealth mode of delivery, when medically appropriate and when the same standard of care can be met as an in-person visit.
Mississippi Division of Medicaid’s Emergency Telehealth Policy, in effect through April 30, 2020, allows rural health clinics to provide telehealth services as the distant site provider. The Division of Medicaid will reimburse all rural health providers delivering a medically necessary telehealth service as the distant site at the current applicable Mississippi Medicaid fee-for-service rate for the service provided. All claims submitted must include an appropriate modifier indicating the service was provided through telehealth.
TennCare and its related health plans has expanded coverage, in effect through April 30, 2020, for the originating site of telehealth services to include “home”. Rural health clinics that submit telehealth claims with “home” as an originating site will be paid by TennCare’s health plans. The visits will also qualify for the enhanced PPS or APM wraparound payments that are made to rural health clinics. Other existing limits and restrictions on what constitutes a visit will still apply.