Six years after the Centers for Medicare and Medicaid Services rolled out the first standalone billing code for remote patient monitoring, there is debate over how the technology will be reimbursed.
The American Medical Association’s CPT Editorial Panel postponed a May vote on a proposal that would have lowered the threshold for how much remote patient monitoring must occur before a provider can seek reimbursement. The editorial panel, which helps curate the AMA's Common Procedural Terminology code system used in billing by CMS as well as other payers and providers, could revisit the proposal at a later date.
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The changes would have shortened how long a provider has to monitor a patient through a remote device in order to submit a bill to a payer. The proposal would have cut the required time to between 2 and 15 days of data and a minimum of 11 minutes of patient interaction in a month, instead of the current 16 to 30 days of data and 20 minutes of interaction.
Medicare’s annual physician fee schedule, which is finalized every November for the following year, may contain changes to remote patient monitoring reimbursement regardless of any decisions by the panel.
The proposal would be a boon to companies in the space — prompting worries they may take unfair advantage of the less strict requirements. The worries comes amid broader concerns over how payers will compensate providers for using different digital health technologies, such as telehealth, since some COVID-19 pandemic-era flexibilities are set to expire.
Most industry observers were not surprised that no action was taken on the proposal. While CMS has added more remote patient monitoring billing codes since the first one was introduced in 2018, the agency is still trying to get understand how to reimburse the technology, said Thomas Ferrante, a healthcare lawyer at Foley & Lardner who advises startups.
“A lot of the industry folks, particularly these new [remote patient monitoring] vendors or the more tech-oriented startup companies, they want to move fast. And that's just not how healthcare in the United States operates,” Ferrante said.
The federal government, through the Justice Department's Office of Inspector General, has raised concerns about companies using remote patient monitoring codes fraudulently. It is one reason why there is hesitancy from CMS and others over expanding reimbursement, Ferrante said.
Remote patient monitoring companies said the uncertainty around reimbursement doesn’t affect their plans for growth, and they understand the hesitation at the federal level.
“The AMA has to strike a balance to encourage the right kind of utilization,” said Chris Altchek, CEO of remote patient monitoring company Cadence. “If they open the floodgates, we may see an influx of low-quality companies using the codes.”
The proposed changes could lead to higher utilization of remote patient monitoring, which would make it easier to gather more clinical data and prove the cost savings of the technology to payers and providers. Patient adoption in general has been a challenge for remote patient monitoring companies. Without adoption, there isn't sufficient clinical data to know how effective the devices are at lowering costs and improving outcomes.
Even when companies do get adoption, it’s unclear the devices are working as advertised. A study published in March from nonprofit research firm Peterson Health Technology Institute found that digital diabetes management tools are not cost effective and few demonstrate clinically relevant outcomes for patients.
"The hesitation right now is whether the juice is worth the squeeze," Ferrante said. "Is this worth the cost? Are we actually improving in moving the needle here for what we're paying for?"
Elisa Harris, a healthcare lawyer at Barnes & Thornburg, works with startup companies on how to take innovative models and make them fit in healthcare’s payment system. CMS will continue to “nibble at the edges” when adding and changing codes, she said.
“It’s going to be three steps forward, two steps back as this technology continues to evolve,” Harris said.
