A Guide To Payer Enrollment For Telehealth Companies
Expanding your payer coverage is key to scaling your digital health company
Let’s be real, the enrollment process can be a bit of a headache for both parties involved. It is, however, crucial to the health and scalability of your telehealth or digital health company.
Thanks to the Omnibus Bill, telehealth services have been made more affordable due to the COVID-19 pandemic and exposure precautions. Most private insurers are required to reimburse some type of telehealth service, but there is still no universal coverage, yet.
Recent policy updates include the Advancing Telehealth Beyond COVID-19 Act that was passed by the House on July 27th. It would allow key waivers that have been barriers to Medicare telehealth reimbursement to run through Dec. 2024.
The push toward increased coverage is a good sign for the industry moving forward. However, it’s still very new. In this blog, we’ll dive into our most recent whitepaper “A Guide to Payer Enrollment for Telehealth Companies”, and cover what to know before you start, types of services, HIPAA compliance, the bottlenecks to look out for and OpenLoop’s own in-network clinician payer coverage.
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Before you start
The enrollment process is notoriously tedious—often causing a lot of hair pulling from both
sides and requiring years of prep work. Here are a couple of the bigger things you should know before you begin that may save you a headache or two down the road.
Defining payer enrollment
Payer enrollment is the process of requesting enrollment in an insurance panel and plan. Acceptance into a network opens up the door to the payers in-network patients and the ability to receive reimbursement for your services. This requires a substantial amount of documents and attention to detail.
Defining credentialing
Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy. It’s part of the enrollment process and required to be accepted in-network.
Do your research first
If you’re reading this, you’re already off to a good start. It’s important to get an idea of which payers are going to make the most sense for you. Here are a couple of tips to help narrow it down:
Contact hospitals in the states or regions you’re looking at and see who they’re in-network with. Chances are, if they think it’s necessary, a large part of the population is covered by it.
Similar to hospitals, contact large employers in the states or regions you’re looking at to see who they’re in-network with.
Establishing physical offices
When you’re looking to acquire a contract with a payer, some may not even entertain the idea if you don’t already have established physical offices in local jurisdictions. Especially for government payers like Medicare and Medicaid, that are state-by-state coverage. This is to ensure those specific communities are provided with healthcare access. As you can imagine, this takes years to develop and can be tricky for telehealth companies to orchestrate properly.
To start, put a list together of the payers you would like to partner with and do your research. That means asking the questions that will cross every “t” and dot all the “i’s”. That way, once you start the enrollment process, you’ll be better prepared and hopefully encounter less bottlenecks.
This isn’t to say it can’t be done, it’s just going to take a lot of work. OpenLoop has spent years building the certified clinician network needed to offer our clients and their patients access to 600+ insurance partners. It’s one of the many ways we make it easier for telehealth companies to expand their patient care.
Types of services and their coverage
Not all telehealth services are covered alike. It differs between private and government insurers on what they will reimburse. Let’s go through what those different services are and what that may mean for their coverage.
Synchronous
Synchronous telehealth is the most well-known and used delivery method. According to the United States Department of Health and Human Services, “synchronous telehealth happens in live, real-time settings where the patient interacts with a provider”.
Commercial and private
Currently, 42 states require private insurers to cover some kind of telehealth service. The type of synchronous coverage depends on the insurer. Be sure to verify each payer's policy.
Medicare and medicaid
Under the 1135 waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients' places of residence according to the Centers for Medicare and Medicaid. This has been extended by the omnibus bill for 151 days after the end of the federal public emergency.
Asynchronous
Asynchronous telehealth, also known as store-and-forward, is the other common delivery method of virtual care. As defined by the National Institutes of Health (NIH), a “patient or physician collects medical history, images, and pathology reports and then sends it to a specialist physician for diagnostic and treatment expertise”. The patient and provider do not interact in real-time.
Commercial and private
The coverage is different from payer to payer. Async is notorious for not being reimbursed due to very specific requirements. However, a push toward more coverage has stirred up discussion about audio-only services. Be sure to verify each payer's policy on which asynchronous services are covered.
Medicare and medicaid
Medicaid now covers some asynchronous services on a state-by-state basis. Federal law limits Medicare's telehealth coverage of asynchronous telehealth to certain projects located in Alaska or Hawaii. Check on your state's policies in the National Policy Center.
Insurers require HIPAA compliant software
Before you even start the enrollment process, double check the software you plan to use to see patients meets HIPAA requirements. That means having secure messaging solutions, hosting services and secure cloud storage services to keep their personal health information (PHI) safe.
Luckily, telehealth compliance is only a click away with OpenLoop’s regulatory and legal services. Within our package of benefits we offer HIPAA, FWA and CCT coaching to help you stay up-to-date on compliance. Or, tap into our pre-vetted and Android/iOS compatible telehealth technology platform that’s customized for your business and patients. The best part? It has HIPAA functionality built right in!
Enrollment bottlenecks
Frequently, health companies come across some bumps in the road during the enrollment process. Nothing is more frustrating than being denied network access after months of work because of something preventable. Here are a few things to keep in mind when enrolling.
Network adequacy/closed networks:
It may be the case that the insurer you’re after already has an exclusive contract with another
telehealth company. Unfortunately, there’s not much you can do about that. It is important, however, to do your research and be ready for it if it does happen.
Too many clinicians in-network
Sometimes insurers will deny providers simply because they have too many. It may save you a lot of paperwork and hair pulling to check with the payer before enrolling your clinicians.
When in doubt, include It
If you think you might need it, put it in the application. Not having enough information could lead to an enrollment denial and make you have to re-enroll. The less times you have to re-do it, the better. For everyone’s sanity.
It’s going to take some time
Enrolling in an insurance health plan is a time consuming process. If you’re applying to multiple at a time, which we would suggest, it may take months just to get all the paperwork finished. Then, you have to wait potentially up to a year for everything to be processed— assuming that everything goes well.
Our goal is to arm you with information that mitigates some of the mistakes seen in the process. As time consuming as it is, it’s a crucial element to the future of your company and the expansion of patient care.
Want access to the full enrollment process and timelines?
Feeling overwhelmed? Tap into OpenLoop.
We get it. It’s a lot. Thankfully, you don’t have to do this on your own! OpenLoop has spent years building a certified network of clinicians covered by 600+ insurance plans. Our providers support over 250 million patient lives and exceed 80% coverage by nationwide insurance payers.
What does partnering with OpenLoop look like?
Comprehensive 50-state payer coverage
Full range of telehealth codes
Virtual care & cash pay focus
Flexible provider credentialing options
Every major insurance payer
Incident to billing coverage
Our expansive network of payer coverage is built to strategically streamline your reimbursement and payment process while expanding your patient network. We have everything you need from first visit to final payment.
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