The Ensuing Challenges of Telemedicine and Reimbursement

Telemedicine has exploded out of necessity to address healthcare needs amidst stay in place constraints,  but it’s created new reimbursement changes especially for the value-based care market.  This is the first in a series of multiple segments to address these challenges and the solutions we need.

While the process was already underway, the COVID crisis has accelerated the breaking down of barriers for healthcare information technology, and the industry is blasting towards an innovation high. Two pandemic factors – the need for social distancing, and the fear of contracting the virus in an in-person healthcare service setting, are pushing lawmakers and regulators towards allowing specific virtual medical visits to be reimbursable at reasonable rates. 

Until recently, CMS and commercial plans applied strict regulations around specific face-to-face visits being reimbursable for risk adjustment purposes.  To address the crisis and the need for social distancing, CMS has modified these regulations and is now allowing certain telehealth visits to be used for risk adjusted patient reviews, assessment, documentation, and coding.

While this is a welcome change by most healthcare organizations, the specifics on how to administer telehealth visits for risk adjustment have been vague and many organizations are struggling with implementing these appropriately.

Top Concerns in Utilizing Telehealth for Risk Adjustment:

Talix recently conducted a survey of over 100 health plans and healthcare providers asking them about their biggest concerns about utilizing telehealth for risk adjustment. The results were very interesting. 55% of the respondents indicated that the ambiguity around telehealth documentation guidelines is their biggest concern.  Other top concerns ranged from patient adoption, a critical mass of patients scheduled, to understanding what diagnosis codes can and cannot be coded from a telehealth visit.

The prolific telehealth concerns are justified as payers and health plans scramble to pivot to new modes of patient engagement.  Questions about security, compliance, coding guidelines, and patient/provider adoption are mounting as telehealth adoption continues to grow. 

In this 5 part blog series, we will provide guidance to health plans and providers to address the challenges of telemedicine reimbursement. 

Feel free to read, chime in and express your point-of-view in the comments fields on each of the blog posts. We hope our insights motivate active discussion so we can all learn through collective wisdom.

Subscribe to the SHIFT blog to be notified when the next Telehealth (and others) articles are posted. The next topic in the series is Telehealth Adoption.  To learn more about Talix’s Risk Adjustment solutions visit

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