Telemedicine and Medicare in 2024

Telemedicine was in use before the COVID-19 Public Health Emergency (PHE) with specific rules and regulations published by the Centers for Medicare and Medicaid Services (CMS). However, the PHE reshaped the landscape of telemedicine overnight to respond to the new challenges of delivering and accessing healthcare services. These changes occurred through the enactment of legislative and regulatory action. Throughout the PHE, patients with Medicare enjoyed broad access to telehealth services. Many of the regulations previously in place were waived to allow patients uninterrupted access to care through telehealth services absent geographic limitations.

The PHE officially ended on May 11, 2023. While expiration of the PHE allowed for some rules and regulations to revert immediately to pre-pandemic status, other waivers or flexibilities were slated to conclude at the end of the year following the end of the PHE (December 31, 2023) or at the end of the year following the end of the PHE (December 31, 2024). It was confusing to many, including myself, as the end of 2023 approached, to know for sure what the status of telehealth would be in 2024.  

One topic that created some extraordinary concern among physicians in the last quarter of 2023, was an expiring rule that allowed physicians to provide telehealth services in their home, while the place of service listed on the claim form was the office. Various experts weighed in stating that that providers would need to register their homes as a place of service for 2024 if they were going provide telehealth services from there. Not until the 2024 Medicare Physician Fee Schedule (PFS) Final Rule was released on November 16, 2023, was it made clear that CMS would extend this flexibility through 2024. It was indicated there will be further consideration of this issue because of privacy considerations. Concern was raised that if physicians were required to register their home addresses in their CMS profile that the address would be on the claim and would compromise the security and privacy of the physician.  

The Consolidated Appropriations Act of 2023 extended many of the Medicare telehealth flexibilities through December 31, 2024, which allowed patients the ability to continue to receive telehealth services in their home. In the 2024 PFS Final Rule CMS reiterated their definition of home to include temporary lodging such as hotels and homeless shelters. It further stated, “for circumstances where the patient, for privacy or other personal reason, chooses to travel a short distance from the exact home location during a telehealth service, the service is still considered to be furnished ‘in the home of the individual.”

During the PHE, CMS allowed licensed physicians and other practitioners to bill Medicare for services provided outside of their state of enrollment. CMS determined that, when the PHE ended, CMS regulations continued to allow for a total deferral to state law. Thus, there is no CMS-based requirement that a provider must be licensed in their state of enrollment. State laws must be understood for both where the patient is located and from where the provider provides care. Remember, CMS does not require a patient to specifically be in their home, but policy does say they can only be a “short distance” from their home. As far as state rules they vary significantly and continue to change. For example, Connecticut rules establish that “providers” include physicians, nurse practitioners, and physician assistants, along with many others who are considered telehealth providers in other jurisdictions. The only broad requirement to provide telehealth services to patients in Connecticut is that the provider carries professional malpractice insurance. As an example, someone from Michigan could provide telehealth services to a resident in Connecticut if they carry professional malpractice coverage. Note, this is only in effect until June 30, 2024, after which new policies come into effect.

As another example of the difference created by geographical considerations, a Michigan provider can provide telehealth services to a patient from Rhode Island only if they work with an air ambulance company or are a charitable volunteer who donates their services, among a few other very specific situations. Florida rules, on the other hand, state that if a healthcare professional is not licensed in Florida, they must register with the applicable board and can only provide telehealth services within the applicable scope of practice established by Florida law. Florida also requires the provider to have malpractice insurance that covers patients that are specifically not located in the provider’s home state. An overview of state license requirements can be found here.    

In closing, if you provide telehealth services, you must consider the following:  

• Have your staff verify and document the state where the patient is located prior to providing telehealth services;
  • If the patient is out of state, those state rules need to be known to avoid compliance problems;
• Document where the provider is located, both state and physical location (i.e. office or home);
• Obtain and document the patient’s consent for the telehealth services;
• Obtain in writing from your liability insurance carrier confirmation that you have coverage to provide telehealth services; and
• Implement a Standard Operating Procedure (SOP) or workflow document to define each of the above steps in detail with alternative options.

Providing telehealth to patients in 2024 is still possible. It is not difficult to follow the rules to provide these services with proper preparation and planning. The important thing is that you identify which waivers and flexibilities changed during the PHE and which are still in effect. Understand how they apply to you and your plan to provide telehealth services to your patients. Do not assume that it is as simple as picking up your smart phone, calling a patient, and billing Medicare. When it comes to commercial insurances, they also need to be researched because each may have their own way of documenting, coding, and billing for telehealth services in 2024 and beyond.