AMA Releases New Insights on Commercial Payer Coverage for Digital Health Care

What is the landscape and decision-making process behind cost and commercial payer coverage for digitally enabled care? New American Medical Association (AMA) research suggests there is a lack of coverage agreement, inconsistent coverage policies within the commercial market, and inconsistent levels of coverage policy transparency when it comes to these new digital health services and tools.

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A new study¹ released by the AMA and Manatt Health aimed to summarize publicly available coverage policies of commercial health insurers for 21 unique digital medicine services to better understand the existing landscape of commercial payer coverage and the decision-making process behind coverage determinations.

“Achieving fair, equitable, and transparent coverage and payment of digital medicine services remains a challenge,” wrote the researchers of the study. “These issues ultimately affect the widespread adoption and accessibility of digital medicine services for both patients and physicians.”

Using AMA Current Procedural Terminology (CPT) billing codes of outpatient and office procedures from 16 commercial payers, the researchers identified which digital health services are funded, as well as any opportunities for improving digital health access.

Here are the 16 commercial payers:

• Aetna
• Blue Cross Blue Shield of Illinois, Massachusetts, Michigan, North Carolina, Texas, and California
• CareFirst Blue Cross Blue Shield
• Cigna
• Elevance Health
• Florida Blue
• Highmark Blue Shield
• Horizon Blue Cross Blue Shield of New Jersey
• Regence
• Tufts Health Plan
• UnitedHealth Group

The billing codes of services included were remote physiologic monitoring (RPM), remote telemetry monitoring (RTM), e-consults (interprofessional telephone/internet/electronic health record assesment provided by a consultative physician) and e-visits (online digital evaluation and management service for an established patient). Furthermore, coverage was categorized according to payer validation, ranging from the CPT code being covered and being covered with limits and unique terms to the CPT code not being covered or the service being allowed through telehealth, but the payer instructs the providers to use different codes.

RPM and RTM billing codes included service initiation, device supply and data transmission, treatment management services, and self-measured blood pressure. Coverage limitations and terms included specific conditions only, frequency limits, not being payable today but will be expected to be payable beginning in the fall of 2023, and temporary coverage through December 31, 2023.

The analysis showed lack of coverage alignment across commercial, Medicare, and Medicaid insurers, with commercial insurance lagging behind Medicare and Medicaid. Despite Medicare and Medicaid providing coverage for all 21 digital health services, some commercial plans had additional requirements beyond what is required of CPT and Medicare. Some of these payers only cover for codes for specific conditions, such as heart failure, chronic obstructive pulmonary disease (COPD), COVID-19, high blood pressure, etc, and some chose not to provide coverage for a specific condition.

Other inconsistencies were identified in the adoption of digital health coverage policies across the commercial market and in the levels of transparency for these coverage policies. Although most commercial insurers cover RPM, coverage is still being evaluated and is less consistent across newer digital therapies, e-consults, and e-visits. Furthermore, although some payers have publicly available clinical coverage policies for telemedicine services, many do not have these telehealth policies publicly available or they are outdated.

Additional discrepancies identified were a time lag for determining coverage policies and limited widespread utilization of most new digital medicine services.

Furthermore, because commercial payers are partnering with telehealth companies to provide these services to their patients, the researchers found these programs are often disconnected from a patient’s medical home or existing primary care physician, which can create further barriers to care.

“While the United States has entered an era when digitally enabled care is integrated with in-person care, the potential of this hybridized care model is not yet fully realized,” said Jesse M. Ehrenfeld, MD, MPH, president of the AMA, in a statement.² “The lack of commercial coverage can be a roadblock or bottleneck to affordable access to digital medicine services for more than half the US population who count on private health insurance. Barriers to clear and consistent coverage policies must be addressed for the pace of digital health progress in medicine to match the technology’s promising potential.”

References

1. Future of health issue brief: bommercial payer coverage for digitally enabled care. American Medical Association. September 18, 2023. Accessed September 18, 2023. https://www.ama-assn.org/practice-management/digital/ama-future-health-issue-brief-commercial-payer-coverage-digitally

2. AMA sheds light on commercial payer coverage for digital medicine. News release American Medical Association. September 18, 2023. Accessed September 18, 2023. https://www.ama-assn.org/press-center/press-releases/ama-sheds-light-commercial-payer-coverage-digital-medicine