Oct. 5, 2021 -- Dave Heal had the best of intentions last year when he began the process to donate a kidney. Unfortunately, during the final testing to ensure the 39-year old was a good candidate, imaging revealed a nodule on his lung. The Colorado-based software professional went from potential donor to potential patient.
As doctors put Heal through a battery of tests to determine what the nodule was, results came up inconclusive.
“They recommended that I get a CT scan every 6 to 12 months to monitor the nodule,” he says, “but they didn’t expect that it would grow.”
Following the recommended protocol, Heal had his first CT scan at 6 months and was told no follow-up was necessary if all remained the same with the nodule.
“I did receive a phone call and then was encouraged to migrate to the telehealth platform,” he explains. “I then received an unexpected bill of $80, and my insurance company was billed $300 for the appointment. I felt this was unnecessary and a revenue-generating scam more than anything.”
Should Heal have been charged for an appointment to discuss his CT results? In a traditional follow-up scenario with a doctor, he might not have been. But with the growth in telehealth -- fueled by the pandemic -- the health care system is still figuring things out.
Telehealth on the scale it has reached today -- analyst firm McKinsey pegs telehealth uptake at 38 times pre-pandemic levels -- is unchartered territory. Learning to navigate it, and the costs associated with it, can be a big undertaking. But as with most things related to health care, it pays to be your own advocate when it comes to telehealth charges.
Billing Is Complex
Chad Ellimoottil, MD, director of the University of Michigan Telehealth Research Incubator, has been studying telehealth from many angles since 2018.
“We’ve been looking into access, cost, and quality of care,” he says. “We predicted telehealth would grow and were interested in the societal effect of it.”
In 2018, the pandemic-explosion of telehealth was just a worst-case scenario in disaster planning.
“At the start of the pandemic, many providers and insurers removed copays for visits because they wanted to encourage telehealth,” says Ellimoottil. “Now we have copays coming back from big insurers. Ultimately, we don’t know yet what the net effect will be for patients, providers, or payers.”
If telehealth leads to an increase in appointments, for instance, costs could go up. According to Ellimoottil’s research, the rate of secondary visits within 7 days is around 10% with an in-person visit. With telemedicine, the rate of follow-ups goes up slightly, potentially adding costs.
But, says Ellimoottil, it’s just as likely that costs could go down.
“If the patient doesn’t have to pay for transportation costs, parking, or take time off work to see a doctor, it could cost less than an in-patient visit,” he says. “But the question remains as to how appointments should be billed with telehealth.”
To understand telehealth billing, Ellimoottil says you should understand the things used in billing for in-person care. “The same considerations apply,” he says.
- The time involved in an appointment. “As the time goes up, the billing does, too,” he explains. “This has always been the case, even with in-person visits.”
- The complexity of the appointment. “The formal term here is ‘medical decision making,’” Ellimoottil says.
- The amount of data reviewed. “If a doctor is looking at an X-ray report versus the actual image, it’s less costly,” he says. “Or if they have to prescribe a medicine versus sending the patient home with Tylenol, the cost goes up.”
In Heal’s case, then, the $80 telehealth bill might have been due to the complexity of reading his CT scans and determining a next course of action, which the doctor then needed to explain to the patient.
“When I asked about the cost, they told me that the doctor spent 35 minutes preparing for the appointment, so it was billed as a full visit,” Heal says.
This goes back to the billing formula.
“Sometimes the appointment itself is short, but because a patient had an acute issue that required tests or a prescription for antibiotics, the billing level is higher,” Ellimoottil explains.
But like Heal, many patients have a hard time appreciating how the cost of telehealth might compare to an in-person visit. Is the quality of care equivalent? In some cases, yes, but many patients question that, and thus the associated billing.
Understanding the System
With telehealth, it’s also important to understand that the method of communication between patient and doctor may be billed differently.
“Early in the pandemic, most programs reimbursed the patient whether a phone call or a Zoom visit,” Ellimoottil says. “But as we move down the road, some payers are covering video but not audio, which can be a surprise for patients.”
This can get more complex, too, when you consider that doctors have varying policies in this regard as well. “The patient can be held victim to what insurance covers, and also how the doctor offers telehealth,” says Ellimoottil.
For patients, then, the best advice is to take an informed approach. “Find out exactly what your insurance covers and what types of visits your physician offers, and ensure they align,” he says.
Also, make sure the visit is going to meet your needs.
“If you’re getting billed for a phone call just to share test results and nothing more, that’s not OK,” Ellimoottil says. “But if it requires a longer discussion with a change in how your care is managed, then it’s justified.”
The patients who are most vulnerable to the potential nickel and diming of telehealth are those with high deductibles, because they most likely won’t meet the billing requirement for reimbursement.
Telehealth is here to stay and may even continue to grow. If you’d like to avoid unpleasant billing surprises, your best approach is to do your homework.
For his part, Heal intends to look for a new doctor in the coming year.
“I wasn’t expecting these out-of-pocket expenses,” he says. “I’m not interested in paying $400 for scans and then $80 for follow-up telehealth visits.”