Introduction:

Telehealth has transformed the healthcare landscape, offering convenience, accessibility, and flexibility to both patients and providers. However, with this digital evolution comes the need for precise billing practices. Mistakes in telehealth claims can lead to denials, delayed payments, or compliance risks. To succeed in 2024’s telehealth environment, providers must understand how to adapt their billing workflows to reflect current rules, payer policies, and best practices.

Verify Patient Eligibility Before Every Visit:

Before initiating any virtual encounter, always verify that the patient’s insurance plan covers telehealth services. This includes checking whether the specific service, provider type, and platform used are eligible for reimbursement. Some payers still require patients to be located in specific regions or settings during the virtual visit, and eligibility confirmation helps prevent non-payable claims.

Know the Correct Place of Service Code:

The place of service (POS) code is critical for ensuring your telehealth claim gets processed correctly. Depending on the payer, the POS code might vary based on whether the provider is in a healthcare facility or working remotely. Assigning the wrong POS code can result in lower payments or outright denials.

Understand Modifier Usage:

Modifiers play a pivotal role in signaling to payers that the service was rendered via telecommunication. Several modifiers are used in telehealth billing, depending on the type of visit, real-time interaction, or asynchronous communication. Applying the correct one ensures full reimbursement and reduces compliance risk.

Keep Documentation Thorough and Specific:

Just like in-person visits, all telehealth encounters must be thoroughly documented. Include the start and end time of the session, modality used (e.g., video or audio-only), patient consent, and all clinical findings. This supports medical necessity and protects the provider during audits or claim disputes.

Use Telehealth-Compliant CPT Codes:

Not all procedure codes qualify for telehealth billing. It’s essential to refer to the most current list of telehealth-approved codes, which is frequently updated by major payers. These codes differ based on service type, such as evaluation, behavioral health, or therapy. Staying current prevents inappropriate code use.

Confirm Licensing and State Regulations:

Billing rules often vary by state, especially in telehealth. Confirm that your providers are licensed in the state where the patient is located, and that local telehealth billing laws are followed. Multi-state licensure is increasingly important for nationwide practices.

Obtain and Record Patient Consent:

Many payers require documented consent from the patient before delivering a telehealth service. Even if the consent is verbal, it must be noted in the medical record. This step ensures regulatory compliance and reassures patients about privacy and participation.

Track Payer-Specific Guidelines:

Every payer has different telehealth policies—some allow reimbursement for audio-only services, others do not. Maintain an up-to-date payer matrix to track guidelines, modifiers, covered services, and documentation needs. This tool will support your billing staff and reduce rejected claims.

Train Staff Regularly:

The telehealth billing environment is constantly evolving. Regular training sessions help ensure that your billing team, clinical staff, and front desk personnel understand the latest changes. Topics like code updates, modifier use, and documentation standards should be part of your training agenda.

Automate Claim Scrubbing and Verification:

Utilize tools that automatically scrub claims for errors, validate codes, and flag issues before submission. Automation enhances accuracy, reduces human error, and accelerates claim processing. These technologies also help identify telehealth-specific billing gaps.

Monitor Reimbursement Patterns:

Track and analyze how payers reimburse your telehealth claims. Look for trends such as lower payments for certain POS codes or higher denial rates with specific modifiers. Insights like these help in adjusting workflows and optimizing revenue.

Bill Based on Time When Appropriate:

Certain virtual visits may be billed based on time rather than complexity. Always document total visit duration accurately, as time-based billing can impact code selection and reimbursement. Be aware of payer thresholds and minimum required minutes.

Capture Non-Clinical Time and Services:

Beyond direct clinical interactions, consider whether care coordination, remote monitoring, or asynchronous services are billable. Many payers now recognize these activities, especially under new chronic care and behavioral health models. Proper coding ensures these efforts are reimbursed.

Audit and Review Claims Routinely:

Build a workflow to audit telehealth claims regularly. This includes reviewing EHR documentation, cross-checking codes, verifying modifiers, and ensuring that provider credentials and licensing align with billing. Early identification of errors leads to timely corrections and reduces the risk of systemic issues.