Digital Health Services Payment Guide Door 1
Welcome to the California Telehealth Resource Center Digital Health Payment Guide! You are about to enter Door 1, your first step toward understanding the fundamentals of digital health. This educational guide is intended for those new to digital health who need to understand the fundamentals, such as provider types, government health programs, the commercial industry, digital health modalities, and the critical components of coding, coverage, and reimbursement.
Each section contains a set of PDF documents that break down the topic into key components. The PDFs are best viewed in Adobe Acrobat Reader, a free PDF viewing software.
You can move through the guide in sequential order or select the sections that are most relevant to you.
To return to the section menu:
– If viewing the PDF in Adobe Acrobat Reader, click the “Back to Door 1” button located at the top of each PDF.
– If viewing from your internet browser, use your browser’s back button.
The 6 Basics for Obtaining Payment:
As you walk through Door 1, you will encounter six key areas essential for obtaining payment in digital health. These areas require a fundamental understanding before you can enter Door 2 – how you will get paid for the services you provide, specific to your patient and provider type.
Already understand the basics? Scroll down and click the button to advance to Door 2.
Provider Type
The first stop will introduce you to the various types of providers, such as Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Indian Health Services (IHS), Critical Access Hospitals (CAH), and community providers. Each provider type has its own billing and reimbursement processes, and knowing your provider type is the first step toward a successful digital health practice.
Health Plan
You will then explore the world of health plans. Major payors such as Medicare (Original Medicare vs. Medicare Advantage), Medicaid (managed care), and commercial insurance significantly impact coverage and reimbursement. This stop will help you understand the rules and regulations for each payor.
Modalities
As you advance through Door 1, you will encounter various digital health modalities. These are Telehealth Interactive Audio-Video, Telehealth Audio-Only, Store and Forward (Asynchronous), Remote Physiological Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Artificial Intelligence, and eConsult. Each modality has its own set of codes and requirements that must be followed to ensure proper billing.
Coverage
In this section, you will learn about the coverage requirements that differ significantly between health insurers and payors. Understanding these requirements ensures that the services you offer are covered and reimbursed. Coverage is determined by the type of provider and the type of service provided.
Coding
Accurate coding is critical for reimbursement, and here you will learn about CPT/HCPC codes, modifiers, and place of service codes. This step of your journey ensures you can effectively communicate the services provided to the payor, allowing for successful claims processing.
Reimbursement
Finally, you will arrive at the reimbursement section. Making sure you are paid appropriately for your services requires that you are aware of the reimbursement rates and procedures for various payors and modalities. You will learn about the reimbursement rates for FQHCs, RHCs, and other providers.
Modalities
Enter Door 2 to Get Paid
Now that you know the basics of digital health payment, you can progress to Door 2 – where you will get down to the nitty-gritty of how to get paid.
Getting paid for your digital health services is an often complex process in which one needs to know the answer to the following questions:
What modality will be utilized?
What provider type are you?
What payer does your patient have?
What are the coverage requirements?
What are the codes?
What are the reimbursement amounts?
First, navigate to the modality that you would like paid, then hone in on the specifics.
