Karen Taylor had been coughing for weeks when she decided to see a doctor in early April. COVID-19 cases had just exceeded 5,000 in Texas, where she lives.
Cigna, her health insurer, said it would waive out-of-pocket costs for 鈥渢elehealth鈥 patients seeking coronavirus screening through video conferences. So Taylor, a sales manager, talked with her physician on an internet video call.
The doctor鈥檚 office charged her $70. She protested. But 鈥渢hey said, 鈥楴o, it goes toward your deductible and you鈥檝e got to pay the whole $70,鈥欌 she said.
Policymakers and insurers across the country say they are eliminating copayments, deductibles and other barriers to telemedicine for patients confined at home who need a doctor for any reason.
鈥淲e are encouraging people to use telemedicine,鈥 New York Gov. Andrew Cuomo said last month after ordering insurers to eliminate copays, typically collected at the time of a doctor visit, for telehealth visits.
But in a fragmented health system 鈥 which encompasses dozens of insurers, 50 state regulators and thousands of independent doctor practices 鈥 the shift to cost-free telemedicine for patients is going far less smoothly than the speeches and press releases suggest. In some cases, doctors are billing for telephone calls that used to be free.
Patients say doctors and insurers are charging them upfront for video appointments and phone calls, not just copays but sometimes the entire cost of the visit, even if it鈥檚 covered by insurance.
Despite what politicians have promised, insurers said they were not able to immediately eliminate telehealth copays for millions of members who carry their cards but receive coverage through self-insured employers. Executives at telehealth organizations say insurers have been slow to update their software and policies.
鈥淎 lot of the insurers who said that they鈥檙e not going to charge copayments for telemedicine 鈥 they haven鈥檛 implemented that,鈥 said George Favvas, CEO of Circle Medical, a San Francisco company that delivers family medicine and other primary care via livestream. 鈥淭hat鈥檚 starting to hit us right now.鈥
One problem is that insurers have waived copays and other telehealth cost sharing for in-network doctors only. Another is that Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare and other carriers promoting telehealth have little power to change telemedicine benefits for self-insured employers whose claims they process.
Such plans cover more than 100 million Americans 鈥 more than the number of beneficiaries covered by the Medicare program for seniors or by Medicaid for low-income families. All four insurance giants say improved telehealth benefits don鈥檛 necessarily apply to such coverage. Nor can governors or state insurance regulators force those plans, which are regulated federally, to upgrade telehealth coverage.
鈥淢any employer plans are eliminating cost sharing鈥 now that federal regulators have eased the rules for certain kinds of plans to improve telehealth benefits, said Brian Marcotte, CEO of the Business Group on Health, a coalition of very large, mostly self-insured employers.
For many doctors, business and billings have plunged because of the coronavirus shutdown. New rules notwithstanding, many practices may be eager to collect telehealth revenue immediately from patients rather than wait for insurance companies to pay, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
鈥淎 lot of providers may not have agreements in place with the plans that they work with to deliver services via telemedicine,鈥 she said. 鈥淪o these providers are protecting themselves upfront by either asking for full payment or by getting the copayment.鈥
David DeKeyser, a marketing strategist in Brooklyn, New York, sought a physician鈥檚 advice via video after coming in contact with someone who attended an event where coronavirus was detected. The office charged the whole visit 鈥 $280, not just the copay 鈥 to his debit card without notifying him.
鈥淚t happened to be payday for me,鈥 he said. A week earlier and the charge could have caused a bank overdraft, he said. An email exchange got the bill reversed, he said.
With wider acceptance, telehealth calls have suddenly become an important and lucrative potential source of physician revenue. Medicare and some commercial insurers for video calls as for office visits.
Some doctors are charging for phone calls once considered an incidental and non-billable part of a previous office visit. Blue Cross plans in Massachusetts, Wyoming, Alabama and North Carolina are paying for phoned-in patient visits,
鈥淎 lot of carriers wouldn鈥檛 reimburse telephonic encounters鈥 in the past, Corlette said.
Catherine Parisian, a professor in North Carolina, said what seemed like a routine follow-up call with her specialist last month became a telehealth consultation with an $80 copay.
鈥淲hat would have been treated as a phone call, they now bill as telemedicine,鈥 she said. 鈥淭he physician would not call me without billing me.鈥 She protested the charge and said she has not been billed yet.
By many accounts, the number of doctor encounters via video has soared since the Department of Health and Human Services that it would take 鈥渦nprecedented steps to expand Americans鈥 access to telehealth services.鈥
Medicare to pay for most telemedicine nationwide instead of just for patients in rural areas and other limited circumstances, HHS said. The program has also temporarily dropped a ban on doctors waiving copays and other patient cost sharing. Such waivers might have been considered violations of federal anti-kickback laws.
At the same time, the CARES Act, passed by Congress last month to address the COVID-19 emergency, allows private, high-deductible health insurance to make an exception for telehealth in patient cost sharing. Such plans can now pay for video doctor visits even if patients haven鈥檛 met the deductible.
Dozens of private health insurers say they have eliminated copays and other cost sharing for telemedicine. Cigna, however, has waived out-of-pocket costs only for telehealth associated with COVID-19 screening. Cigna did not respond to requests for comment.
Teladoc Health, a large, publicly traded telemedicine company, said its to 20,000 medical visits a day since early March. Its stock price has nearly doubled, too, since Jan. 1.
With such a sharp increase, it鈥檚 not surprising that insurers and physicians are struggling to keep up, said Circle Medical CEO Favvas.
鈥淚t鈥檚 going to be an imperfect process for a while,鈥 he said. 鈥淚t鈥檚 understandable given that things are moving so quickly.鈥
Abbie VanSickle, a California journalist, wanted her baby鈥檚 scheduled wellness visit done remotely because she worried about visiting a medical office during a pandemic. Her insurer, UnitedHealthcare, would not pay for it, the pediatrician told her. Mom and baby had to come in.
鈥淚t seems like such an unnecessary risk to take,鈥 VanSickle said. 鈥淚f we can鈥檛 do wellness visits, we鈥檙e surely not alone.鈥
A UnitedHealthcare spokesperson said that there was a misunderstanding and that the baby鈥檚 remote visit would be covered without a copay.
Jacklyn Grace Lacey, a New York City medical anthropologist, had a similar problem. She had to renew a prescription a few weeks after Cuomo to waive patient cost sharing for telehealth appointments.
The doctor鈥檚 office told her she needed to come in for a visit or book a telemedicine appointment. The video visit came with an 鈥渁dministrative fee鈥 of $50 that she would have had to pay upfront, she said 鈥 five times what the copay would have been for an in-person session.
鈥淚 was not going to go into a doctor鈥檚 office and potentially expose people just to get a refill on my monthly medication,鈥 she said.
