Medicare Reimbursement for Virtual Services – A Matter of Health Equity
Published April 22, 2022

A PYA Perspective: Medicare Reimbursement for Virtual Services – A Matter of Health Equity

Thoughts, Experiences, and Stories From the Field by the Experts at PYA

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has expanded Medicare reimbursement for virtual services, including chronic care management, remote patient monitoring, virtual check-ins, and e-visits. However, CMS limits coverage for these services to established patients. This requirement was waived during the COVID-19 public health emergency but will be reinstated unless CMS changes its rules.   

In effect, CMS’ established patient rule means a Medicare beneficiary may access these virtual care management services only if the beneficiary’s provider furnishes them. At present, only a small number of providers make these services available to their patients. In 2019, the most recent year for which utilization data is publicly available, fewer than 24,000 practitioners billed Medicare for chronic care management services (CPT® 99490). This represents approximately 10% of the primary care physicians participating in the Medicare program. Fewer than 1,000 practitioners billed Medicare for remote patient monitoring that same year (CPT® 99453, 99454, and 99457). As a result of the established patient requirement, the majority of Medicare beneficiaries are denied access to these virtual services.

Medicare beneficiaries residing in underserved and rural areas are more negatively impacted. A higher percentage of these Medicare beneficiaries lack an established relationship with a primary care provider due to provider shortages. And rural providers are less likely to have the resources needed to establish virtual services programs in their practices.    

As a matter of health equity, these beneficiaries should not be denied access to virtual services. Instead, providers capable of furnishing these services across a broader population should be able to initiate services with a beneficiary with whom the provider does not have an established relationship. To ensure continuity of care for those beneficiaries with a primary care provider, the virtual care provider should share relevant information on a regular basis with any provider identified by the beneficiary. These types of collaborative care arrangements benefitting rural residents should be encouraged by Medicare payment policy, not limited by the established patient requirement.   

While CMS may consider the established patient requirement as a protection against fraud and abuse in the provision of virtual services, there are more reasonable safeguards than one that denies beneficiaries access to care. For example, CMS could require the provider to give specific notice to new patients receiving virtual services.

Virtual care holds great promise in promoting health equity by eliminating barriers to care. However, that promise can be realized only if there is equal access to these services.

If you would like more information about Medicare reimbursement for virtual services, or would like assistance with any matter related to compliance, strategy and integration, or valuation, one of our executive contacts would be happy to assist. You may email them below, or call (800) 270-9629.

Executive Contacts

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