The behavioral health landscape has experienced seismic changes over the past decade, in large part due to the growing footprint of telehealth. While it once may have seemed the realm of sci-fi to fire up a tablet and conduct a behavioral health session remotely, this practice is becoming more and more common. The benefits to online behavioral therapy are many for both patient and practitioner, and insurance companies are beginning to realize this.
Increasingly, Medicaid, as well as private payer insurance, cover online counseling and video therapy sessions. Because it’s still an emerging field, policy surrounding behavioral telehealth varies significantly between states. Understanding the factors that affect compensation will improve your ability to seek reimbursement for your telehealth patients.
If you are considering offering video and phone therapy sessions in your practice, you may wonder if your patients will have insurance coverage for telehealth or telemental health services. Here are the answers to some of our most frequently asked questions.
Table of Contents
- Telemedicine vs. Telehealth: What’s the Difference?
- What Is Telepsychiatry?
- What Are the Benefits of Telepsychiatry?
- Will Insurance Companies Reimburse Clinicians for Telehealth Services?
- How Do I Determine If Private Insurance Will Reimburse Virtual Therapy?
- How Can I Challenge a Denied Telehealth Claim?
- How Do Reimbursement Rates Differ for In-Person vs. Online Therapy Sessions?
- What Are Some Advantages to Telehealth Sessions?
- What Is the Mental Health Parity Law and Why Is It Important?
- What You Should Know Before You Begin Telehealth Therapy Sessions
- What Does the Future Look Like for Telepsychiatry & Telehealth?
- How Detailed Therapy Notes Can Help
Telemedicine vs. Telehealth: What’s the Difference?
The terms “telehealth” and “telemedicine” are often used interchangeably, but there are some differences between them. What is telehealth? The word has evolved into an umbrella term that encompasses a wider variety of remote and digital healthcare services. The Health Resources and Services Administration (HRSA) splits the definition of telehealth into four applications.
- Live video conferencing: A two-way link between a care provider and a patient with both audio and video components.
- Store-and-forward video conferencing: The transmission of a recorded health history to a practitioner. This is most common when patients need to interact with specialists.
- Remote patient monitoring: The use of various devices to monitor and record medical data for review by a provider in a different location.
- Mobile health (mHealth): Any form of health care or public health information that patients and providers access via mobile devices.
Telemedicine is defined as any diagnosis or treatment of patients in a geographically separated location through telecommunications technology. It includes physician activities like interpreting x-rays for a patient in another state, explaining the results of a blood test to a patient via video call or performing consultations in non-urgent scenarios. Telemedicine is a valuable tool in serving patients in rural locations who may not be able to travel to see a specialist in a larger city.
Behavioral health services can sometimes fall under the category of telemedicine. If you’re a psychiatrist or psychiatric nurse practitioner, your services may be covered under telemedicine. Psychologists, counselors and therapists provide services that are often referred to as “telebehavioral health” or “telemental health.” These terms fall under the general umbrella of telehealth, and that’s how you will bill for reimbursement.
What Is Telepsychiatry?
Telepsychiatry is a subset of telemedicine. It may involve a psychiatrist providing services such as psychiatric evaluations, therapy and management of prescribed medications. It may also involve a psychiatrist coordinating with primary care providers. Telepsychiatry services include therapy sessions, diagnosis of mental health disorders, medication management and emergency crisis intervention. These services may be performed via video chat, phone, or sometimes even text messaging.
One concern many practitioners have about conducting psychiatric therapy via Skype or other videoconferencing services is the efficacy of the practice. It may seem like a strange idea as so much of psychiatry depends on observation of the patient. In recent years the advancement of communications technology has made videoconferencing as crisp and clear as if you were there in person, and research supports this notion.
A formal review of telepsychiatry in the 21st century shows the practice to be as effective as traditional methods. One of the studies cited found that 83 percent of patients diagnosed with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) using telepsychiatry received a correct diagnosis. Another study cited showed that rural patients using telepsychiatry received a wrong diagnosis only one to two percent of the time.
What Are the Benefits of Telepsychiatry?
Telepsychiatry and telemental health services have a range of benefits for both the patients and the practitioners. For patients, the greatest benefit may be increased access to mental health services. People in rural areas who live miles from the nearest grocery store are unlikely, and in many cases, unable to physically visit a mental health specialist. The elderly are another vulnerable group who have difficulty accessing medical and behavioral health care.
Even people who are otherwise able to attend in-person sessions may be more likely to engage in treatment when they can participate in sessions from their home. The convenience of telepsychiatry cannot be understated. Other benefits include:
- Better integration of behavioral health care and primary care
- Reduced need for trips to the emergency room
- Reduced delays in care
- Improved continuity and follow-up in care
- Reduced barriers of stigma
Many patients that have a hard time opening up can benefit greatly from telemental health care. Conducting sessions from the privacy of their own home can make them feel safer and more secure, making them more likely to cooperate with the practitioner.
Will Insurance Companies Reimburse Clinicians for Telehealth Services?
There is no easy answer to this question. Not only do the guidelines for insurance reimbursement for telehealth vary from state-to-state, but they can also depend on the type of healthcare you are offering. For example, even if live telehealth sessions are covered, “store and forward” sessions may not. (A “store and forward telehealth session” is one where the patient provides important data for the clinician to analyze and diagnose electronically, but they do not interact directly.)
If you are providing telemental health services, store and forward will usually not be an issue. However, there are a limited number of CPT and HCPCS codes that are eligible for telemedicine health reimbursement, and there are many more codes for physical health diagnoses than mental health diagnoses on the list.
Even if you have a covered therapy, some insurance providers, like Medicare, may not offer reimbursement unless the patient is in a rural area where accessing in-person medical care is difficult.
The Center for Connected Health Policy (CCHP) has created an interactive policy map of current state laws and reimbursement policies on telehealth. They have also compiled a report that details the regulations of all 50 states, which you can use to determine what Medicaid and private payer laws are active in your area.
Here are some statistics to know about insurance and telehealth:
- All 50 states and Washington, D.C. provide reimbursement for live video sessions in Medicaid fee-for-service.
- There are 23 states that limit where patients can receive telehealth services.
- There are 14 states in which the home is an eligible place for patients to receive telehealth treatment.
- There are 39 states plus Washington, D.C., that have laws governing private payer telehealth reimbursement.
If your patient is using Medicaid, your telehealth services will be covered. Medicare also covers telehealth services as long as they are on the approved list. Other conditions that must be met for reimbursement include the following.
- The service has to be provided using an interactive telecommunications system with real-time audio and video communication.
- The service must be provided by a physician or other authorized practitioner.
- The person receiving the service must be located in a telehealth originating site.
These restrictions are more stringent than they may first appear. Psychiatrist phone sessions do not warrant coverage because the sessions must have an audio and visual component. The platform you use must also be compliant with the Health Insurance Portability and Accountability Act (HIPAA).
Authorized practitioners include psychiatrists, nurse practitioners, clinical psychologists and clinical social workers. Counselors and marriage and family therapists are not currently authorized practitioners, although that may change in the future.
The originating site stipulation is an important factor to keep in mind. While the prevailing vision of telehealth is of a patient receiving treatment at home through video therapy sessions, that may not be the case in your location. As mentioned above, only 14 states consider the home a valid originating site for Medicare or Medicaid-reimbursed telemental health. Be sure to brush up on the rules in your state.
How Do I Determine If Private Insurance Will Reimburse Virtual Therapy?
Does insurance cover online therapy? Individual insurance plans may or may not cover telehealth. In the majority of states, there is a telehealth parity law that requires that all insurance plans cover telehealth at the same rate as they would for in-person sessions. If you have a patient interested in telemental health treatment, you’ll have to do some sleuthing to find out what exactly their insurance plan covers. For instance, some insurers will cover therapy over the phone, even though Medicare and Medicaid require a video element.
The smartest thing to do is contact the insurer directly. Check and verify coverage and note any limitations in the plan. Even when two patients are covered by the same company, one might have telehealth coverage and the other might not. Find out if there are any extra steps you need to take to provide telehealth that is covered under the plan. You may have to be pre-authorized or be on the insurer’s telehealth provider list. Some companies may require some form of proof that you have comprehensive knowledge of the state’s telehealth laws. You won’t know unless you ask.
Make sure you keep detailed records of the call. Note the number you called, what department you reached, who you spoke to and what they said. If possible, get a call confirmation number. Hopefully, you won’t need to use this information, but it may come in handy if you find yourself fighting a denied claim.
How Can I Challenge a Denied Telehealth Claim?
If you have done your due diligence in research up to this point and are confident the denial is not due to a mistake on your part, here’s what you should do to challenge a denied telehealth claim.
- Find and copy the appropriate state legal statute and its source. Forward the information to the payer with a link if applicable.
- If they do not respond to the legal information, it’s time to get other entities involved. Seek resources from the Telehealth Resource Centers or the CCHP to help you challenge the denial.
- If you are part of a professional association at the state or national level, reach out to their advocacy department to see what they can do for you.
- The Department of Insurance in your state may be a good resource to contact.
- If the issue does not get resolved, you may want to enlist the help of the governor or other officials to bring attention to the issue.
How Do Reimbursement Rates Differ for In-Person vs. Online Therapy Sessions?
Again, this varies according to state. In some states, providers are required to reimburse for telehealth at the same rate as they would a comparable in-person event, while others, even if they require reimbursement, may not set guidelines as to the level of reimbursement they must offer.
What Are Some Advantages to Telehealth Sessions?
The most obvious advantage of telehealth sessions is that it will allow you to provide care for patients who would otherwise struggle to get to your healthcare facility, either because of distance, a lack of accessible transportation from their location, or a health problem that limits their mobility. Telehealth can also offer people who move away from their doctors to maintain continuity of care.
Telehealth sessions may also be offered at a more affordable rate, since they require fewer of the healthcare provider’s resources.
What Is the Mental Health Parity Law and Why Is It Important?
The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 is a federal law designed to stop group health plans and insurers from providing less coverage for mental health problems than for physical illness. Insurers can’t institute higher co-pays or deductibles for mental health treatment, and they can’t set limits on what they’ll pay for that care.
The MHPAEA does not explicitly cover telehealth, but it does provide a foundation for telehealth insurance reimbursement. For example, if a group health plan covers telemedicine for medical and surgical reasons, they would likely also have to cover telepsychiatry or other telebehavioral health to be compliant under MHPAEA.
The majority of states have enacted their own parity laws specifically requiring that telehealth receive equal coverage on par with traditional in-person care. Each law is a little different, so it’s crucial to be familiar with your state and every state you intend to provide telehealth services in.
What You Should Know Before You Begin Telehealth Therapy Sessions
Is online counseling right for your practice? Take these five considerations into account before you begin offering telehealth options.
Because remote telehealth often involves patients that are in a different state — whether permanently or temporarily — it’s essential to know where you need to be licensed. If you plan to serve patient across state lines, you will need more than one state license. The majority of states require that practitioners be licensed to practice in the state where the patient is receiving care.
For this reason, you must be selective about the patients you take on. You don’t want to dive into remote behavioral health and have to get licensed in seven different states just to cater to a small pool of patients. Some mental health professionals prefer to keep things simple and only operate within the state in which they’re already licensed to practice.
2. Telehealth CPT Codes
Getting your Current Procedural Terminology (CPT) codes right is essential to getting reimbursement from payers. In the past, CPT codes used the modifier “GT” to indicate a telehealth session. That modifier has now been phased out and replaced by “95”. When filling out the CMS-1500 claim form, you will use the regular CPT code and add the 95 modifier to Box 24D under the column marked “Modifier.” These are some of the most common telemental health CPT codes you’ll use when providing telebehavioral health care.
- 90791: Psychiatric diagnostic evaluation.
- 90837: Psychotherapy, 60 minutes with patient.
- 90839: Psychotherapy for crisis; first 60 minutes.
You will also need to fill in the Place of Service Code with “02” in Box 24B to indicate that the session was telehealth care. You can only use CPT codes for telehealth psychotherapy for sessions that comply with your state’s criteria for telehealth. For example, Colorado’s Medicaid telehealth policy does not include telephone-only communications in its definition of telehealth, so you would not be eligible to receive reimbursement for a 90791 code if a session was conducted via phone conversation.
Falsifying telehealth CPT codes can be considered fraud, even if you do it by mistake. A thorough understanding of CPT codes and their application to telehealth is a must if you want to incorporate virtual therapy into your practice.
As you have realized by now, the process of receiving reimbursement for telehealth care is more complex than it is for traditional, in-person care. Because mental health services delivered remotely are still quite a new phenomenon, you may experience some frustration dealing with a large number of non-uniform policies. If you practice in one of the few states with no telehealth parity law, getting reimbursement may be challenging.
The CCHP is a comprehensive resource for learning about your state’s laws and how to apply them to your telemental health care.
4. HIPAA-Compliant Platforms
You can’t just pick up your iPhone or hop on Skype to conduct a session because neither Skype nor Facetime is compliant with HIPAA requirements. While you won’t be doing therapy via Skype, there are plenty of platforms you can use to safely and securely connect with your patients. Finding the best telehealth app for your practice is one of the most critical steps to becoming telehealth-ready.
HIPAA-approved providers have to provide audit controls to keep track of everyone who has accessed a patient’s private health information (PHI). They must also give the appropriate parties notice if any data breaches occur. Three of the best compliant online psychiatrist apps for video therapy sessions include Signal, VSee and Doxy.me. Both Signal and Doxy.me have free options for small or solo practices, making them good options if you are not quite ready to commit fully to telehealth.
5. Challenges of Telehealth
Telehealth has come a long way in the past several years, though challenges remain in its implementation. For behavioral health specialists, these are three of the biggest barriers to telehealth.
- Technological literacy: Some patients may not have the technological literacy or access to communication devices necessary for telemental health care.
- Representational accuracy: While technology has improved, telehealth communications sometimes leave out details, such as someone clenching their fists while talking about a certain subject. The higher the quality of the communication device, the less of a problem this is for diagnosis and treatment.
- Lack of regulatory consistency: Perhaps the most difficult and time-consuming aspect of telehealth is doing your homework on the different rules and regulations of each state, as there is no uniform policy governing the field on a national scale.
Many patients and practitioners find that the benefits of remote behavioral health care easily tip the scales to make the challenges worth it. Once you build a sufficient knowledge base, overcoming the challenges becomes easier and more routine.
What Does the Future Look Like for Telepsychiatry & Telehealth?
As more of our world goes digital, the time may come when all sessions that do not actually require a direct examination by the doctor will be administered remotely. Even before this happens, the atmosphere promoting progressive healthcare may result in greater coverage for mental health and for telemental health services in particular.
How Detailed Therapy Notes Can Help
Documentation is always key to receiving reimbursement for mental health services, but it becomes even more crucial in telehealth. Because remote health care is still relatively new, it faces more scrutiny from payers. The less comprehensive your notes, the more likely it is that a payer will try to find holes in your claim.
Telehealth parity laws go both ways. To receive equal reimbursement for remotely conducted sessions, your notes have to be of equal quality. Telehealth and a great electronic health record system (EHR) go hand in hand. With a robust EHR, you’re empowered to quickly and accurately take detailed notes in a variety of formats, such as SOAP notes. You can create thorough, comprehensive psychotherapy or psychiatric notes in just minutes with the right EHR.
ICANotes is the most robust EHR designed for behavioral health professionals. The full-featured platform was created by a clinical psychiatrist to address multiple pain points found in both traditional and telehealth settings. The suite of benefits includes partial automation of:
- Notes and charting
- Document management
- Secure messaging
- Patient portal
Why choose ICANotes as your EHR and practice management software?
Whatever your state’s current policies are on telehealth and telemental health reimbursement, it is critical that you have accurate electronic documentation of all your remote sessions.
ICANotes offers the only fully configured Electronic Health Records software for behavioral health or addiction treatment. With HIPAA compliance built right in, automatic CPT coding at the highest reimbursement rate and a strong support team to help you get started, ICANotes presents a quick and intuitive way to get improve your practice’s efficiency as you make the move toward offering telehealth care.