Telehealth Billing Update 2021

In this Ask A Biller webinar, insurance expert Barbara Griwold, LMFT, discusses all the new updates to billing insurance for telehealth services. 

Hosted by SimplePractice’s insurance specialist Avery Lopez, they discuss everything from the correct way to bill telehealth sessions with a CPT code modifier to what the future of insurance coverage looks like for telehealth. Barbara also answers questions about seeing clients who may be located in other states, and what is on the horizon for insurance post COVID-19.

1. ​​Introductions
2. For those of us new to telehealth billing, can we get a basic run-through on what current billing looks like?
3. How do I find the right modifiers and place of service codes for a particular plan?
4. If I’m at my office and I have a virtual session with a client, do I bill it as a telehealth or regular office session?
5. I’m planning on continuing telehealth indefinitely. What is the outlook for insurance coverage in 2022 and after the pandemic?
6. Have Medicare and Medicaid covered telehealth and will it continue?
7. Are there any special telehealth issues for therapists who only issue superbills out-of-network?
8. What are the rules about providing therapy to a client in another state? When is it legal? Will insurance cover that?
9. Will insurance cover me if I have a telehealth-only practice? Do I need to keep a physical office space even if I work from home?
10. What needs to be recorded in the notes for telehealth services?
11. Will reimbursement rates decrease for telehealth sessions?
12. So much is unknown for the future. What should we be thinking about?
13. Are insurance plans requiring us to use a HIPAA-compliant telehealth platform?
14. Are there types of clients for which insurance will not cover telehealth services?
15. Prior to the pandemic, did most insurance companies cover telehealth sessions for behavioral health?
16. What else do we want to say that we didn’t get time for?
17. Is the BAA just signed by the provider or also each client?
18. If I want to continue to provide services via telehealth, is the featured contract with telehealth companies?
19. Are there any issues with clawbacks for out-of-network providers doing telehealth?
20. Is it common for insurance companies to request a W-9 nine from the clinician after a client submits a superbill claim?
21. If the provider is on vacation out of state, could they still provide telehealth sessions to in-state clients?
22. Does the telehealth consent form have to be renewed yearly?

​​1. Introductions

Avery Lopez: Hi, everyone. Thanks for joining us. Welcome to this segment of Ask a Biller. Today, we’re going to be talking about telehealth billing, the update for 2021. So just really quickly to briefly talk about our agenda here, I’m just going to introduce our speakers really quick. And then we’re going to go ahead and answer all of the pre-submitted questions that we have.

So I’m Avery, I’ve been working in the healthcare industry for about three years now. And after working so closely with a bunch of healthcare providers, I’ve come to understand how important understanding how insurance works is. So in my current position, I’m just happy to be able to go ahead and contribute to the knowledge people out there have so that they can do their jobs more easily and everything else. I’m privileged to be able to be doing all of this.

And then for the woman of the hour, Barbara Griswold. She’s a practice consultant and author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working With Insurance – And Whether You Should. And it’s now in its eighth edition. Last year she celebrated 30 years in private practice. And her goal is to help every therapist feel as confident about their business as they do about their therapy. So she invites you to contact her at her website, theinsurancemaze.com.

So now we’re moving into it here. We have this, just to let you guys know, if you’re new to insurance and you haven’t seen any other Ask a Biller series or any other Ask a Biller video, you can go to this website, simplepractice.com/ask-a-biller-series. And all you have to do is enter in your email and you’ll get access to all of our previous videos and you can watch all of those and gain any insight you can from them.

One thing is that this is a separate thing from SimplePractice, so it’s not actually going to be explaining how SimplePractice works or anything. It’s on its own, so keep that in mind. But otherwise, we’ll get to it now.

So we have, like I said, the telehealth billing update for 2021, and here are the questions that were pre-submitted. So the first one, “For those of us new to telehealth billing, can we get a basic run-through on what current billing looks like?” From Margie. A.

Barbara Griswold: Well, first I just want to say hi to everyone, Barbara Griswold here, and I’m delighted to be asked to do these every couple of months for SimplePractice. And we’re going to try to cram as much as we can into one hour. Your questions are not all going to be answered because there’s so many questions that are out there about telehealth billing, but I’m glad that Margie asked this so we can just do a quick review.

And I also want to say, there’s really no way I can talk about what is true for everyone, every plan across the country, every state, but we’re just going to do some generalities.

2. For those of us new to telehealth billing, can we get a basic run-through on what current billing looks like?

Barbara Griswold: All right. So when you’re billing for telehealth, in general, you’re going to use the same CPT codes that you use when it’s in person. And the CPT codes are those five-digit codes that tell the insurance plan what kind of service you provided? Like a 90834 for an individual 45-minute session, or a 90847 tells them it was a couple session or family session.

So you’re going to use those same codes that you would have used if this was an in-person session, however, you’re going to have a few differences. Usually, you’re going to use a different place of service code, also called a POS code. You’re going to switch that from 11, which is office, to 02 or 2, which indicates that it was a telehealth session.

Now, if you’re an out-of-network provider, you’re like, “What? What’s this? I never used a place of service code.” But when you don’t put down a place of service code, it is assumed on your superbill or your invoice, it’s kind of assumed it was an office session. So you need to let them know. And I’m going to show you these on an invoice and on a claim form, so you know where these are. But you’re going to need to switch the place of service code usually to 02.

However, let’s go forward here, some plans do still want the normal place of service code like if you were in your office, even though you’re doing a telehealth session, so you have to be very careful, including usually Medicare. And again, I’ve seen some different things about that, check out with your Medicare, but Medicare has traditionally, up until now at least, wanted you to keep using the normal POS code, Tricare. So some of these federal plans may still want you to use the normal.

So one of my points here is don’t make assumptions. You can never make assumptions, but if you don’t know, I would say usually you’re right if you use the 02 code for place of service code.

Okay, what else needs to be different? You may need to add a modifier. In most cases, you’re going to have to add a modifier. What’s a modifier? We’ve never had to use these before. These are a two-digit code that you would add to, again, tell the insurance plan this was a telehealth session.

Now, usually, the modifier that tells them that is 95. 95, though, the old modifier for telehealth, GT, is still often accepted. I think I saw one plan that actually required it. So each plan is a little bit different. You’ll have to check out with the plan. I’m going to say that like 95 times today, you got to check with the plan.

Keep going, yeah. So don’t assume. For example, regions, they changed what POS code and what modifier codes they wanted for services after July. So these plans are even changing. So like, “Oh, for dates of service before July 1st, we want this modifier and this POS code. And then after that, we want you to change it completely.” So again, don’t assume, check back with plans.

Now, phone sessions are usually coded the same as video. And this is just a quick reminder, now that some of us are back maybe seeing in-person sessions, don’t forget to switch these codes back. Sometimes we forget and we just keep leaving them in there as telehealth sessions when they’re now in person, so you’re going to have to go back to the old place of service code and take off that modifier.

So I want to show it to you on a claim form. Look at, again, if you would, Avery, so this is where you would put the place of service code. There’s a place right there on the claim form in 24B, you’d put that 02. Same CPT codes. And that’s where the modifier would go. First, they give you a modifier, they give you places for four modifiers, four columns basically. Just put it to the right there. Don’t stick it in there with the CPT code.

Now, if you’re out-of-network and you’re submitting some kind of a superbill or giving a client a superbill or a statement, you’ll see, click it again, Avery, you’ve got the place of service code there, you got your modifier there. And it would be good to have a service description that just drives home that this was a video session.

Now, I’m guessing your superbill or statement doesn’t look like this. So I’m going to encourage you to add a modifier place of service columns if you don’t have those just to, again, drive it home. If you don’t have superbills, if you don’t have claim forms, I do have a practice forms packet that has those in there, and you can get that on my store page on my website.

Avery Lopez: So the second question we have here is, “How do I find the right modifiers and place of service codes for a particular plan?” From Jeff R.

3. How do I find the right modifiers and place of service codes for a particular plan?

Barbara Griswold: Again, the biggest mistake people are making is assuming. They’re assuming that telehealth is always covered. They’re not checking coverage, and they’re making assumptions about what modifiers to use or not to use modifiers or blah, blah, blah, blah. So I strongly recommend that you check benefits by phone before you see the client, and again in January of each year.

And besides doing the usual questions that you’re going to usually ask for non-telehealth people, you’re going to have some additional questions when you do telehealth, so here are just some sample ones on this next slide. I’m now network or out-of-network, is telehealth for psychotherapy covered? Until when? And they may not have an answer for that, but good to ask. Is it only for COVID-related visits? This is a big one that sometimes people are out there and you have to watch out for stuff that’s on the internet.

They’ll say, “Oh, this insurance plan is covering blah, blah, blah.” Well, if you look very deeply, it may be that they’re only covering psychotherapy if it’s a COVID-related visit or they’re only covering telehealth when it’s a medical COVID-related visit. So you have to dig a little bit deeper sometimes.

Are video and phone sessions covered? Is a modifier needed? Is 95 the correct modifier for both phone and video sessions? Now, you notice how I phrased this sentence, just going to stay on that for a minute, if you call them up and say, “What’s the modifier we need to use?” Sometimes they’ll say, “Well, we can’t give billing advice.” But if you ask them, “Is 95 the right modifier?” They can sometimes say yes or no. So it’s kind of silly, but it’s true. And the same thing with, “Do I need to use place of service code 02?”

Are copays and deductibles waived for telehealth when the client sees me? Until when? So many of us know that during the pandemic, a lot of people’s co-payments or deductibles, their cost-shares they’re called, have been waived to make it free for clients to see us.

Even within the same health plan, I just want to point this out, I have three different Blue Cross clients, one of them has had their co-payments waived the entire time. One had it waived for a period of time, and then as of September 1st, they stopped being waived. One never had them waived. So even within the same health plan, it can be very specific to your client’s account. So you have to call on each person to find out, are their deductibles being waived? All these things. What are their particular plans? And then for how long, and is it only for COVID-related visits? Again, that same question.

But I have got you covered. I have created for everyone who’s watching this, what I call my one-stop shop. I created a checking coverage handout, which is going to tell you what you need to ask your client and then what you need to ask the plan. And there’s lots of telehealth questions on there, but you can use it for non-telehealth, for in-person sessions too. So there’s a sheet that you can use and copy and use it in your practice.

Again, at this website, it’s going to be a place where you’re going to get another link, another handout that I’m going to talk about later today, which is what to ask plans when you give up your office or your practice across state lines, so there’s a list of questions. You can get the slide handout for today, since there’s so much stuff that’s packed in here today.

And any resource I mentioned today, as we talk, instead of giving you 95 links, I decided I’m just going to put all the links to any resource I mentioned today on this one page, so it’s all there. So go to theinsurancemaze.com/TH for telehealth. Just take a minute to write that down now, or maybe somebody can copy it into the chat or the Q&A so people can copy it. And we’ll give you that several more times today. You can also go there to ask any follow-up questions you have that don’t get answered today.

Now, I also have another resource. I’m a little hesitant to give it because it may be a bit out of date. But at the beginning of last year, I went through every plan I could possibly find out there across the United States and try to do a plan-by-plan outline of their insurance coverage for telehealth. That link is also on that one-stop shop page.

Now, some of this has been updated since then, some hasn’t. It’s just a massive project that’s too hard for me to spend too much time updating, but it might give you some jumping-off points in terms of some websites. Again, we’ll be on the one-stop shop page if you want to look at the plan-by-plan outline of insurance coverage.

Avery Lopez: So the next question here, “If I’m at my office and I have a virtual session with a client, do I bill it as a telehealth or regular office session?” From Jacie T.

4. If I’m at my office and I have a virtual session with a client, do I bill it as a telehealth or regular office session?

Barbara Griswold: Yeah, this is a great question. So if you’re at your office and you have a virtual session, you are still billing it as a telehealth session. It doesn’t matter where you’re sitting, you could be in a library, you could be at your home, you could be in your pajamas, it doesn’t matter.

If it’s a telehealth session, that’s where you’re billing it as a virtual session and you’re going to use those same 02 place of service code. So where you are does not make a difference in terms of the billing codes.

Avery Lopez: “I’m planning on continuing telehealth indefinitely. What is the outlook for insurance coverage in 2022 and after the pandemic?” From Cassie L. and Lenny P. and others.

5. I’m planning on continuing telehealth indefinitely. What is the outlook for insurance coverage in 2022 and after the pandemic?

Barbara Griswold: So I usually save this one for the end of the presentation, but I thought I’m just going to give you this one since this is what a lot of people have come for. I’ll come give it to you early because I know it’s really important.

I wish I could give you a clearer picture of what’s coming. This is the one that we all would like, the crystal ball, so that we can prepare and we can prepare our clients, but we really… It’s very fuzzy out there. I wish I could tell you more. Insurance plans are not doing a really good job of making some policies being clear and saying, “Okay, from now on, this is going to be our policy about telehealth.”

A lot of them are taking a big wait-and-see approach, but here are my five predictions. I think coverage is going to expand from pre-COVID, but not as uniformly or robustly as we think. I think we all think that there’s going to be some sweeping mandate that comes down from on high and all of a sudden, telehealth is going to be covered. And I think we’re going to be really gravely disappointed. It’s not going to happen like that at all.

Many plans have based their expansion of telehealth on the Public Health Emergency declaration, the PHE. Now the current… This PHE gets pushed back every three months, every three months. They aren’t able to say, “Let’s do that for all of 2021.” So they last pushed it back until October 18th. And probably October 18th they’ll push it back again another three months. It’s crazy, but this is how they have to do it.

And President Biden has expressed a desire to at least continue it until the end of 2021, but he doesn’t have all the control to do that himself. He has to ask the folks who are in charge of the PHE. But not all states and plans are following the federal PHE. They all have their own ability to have a public health emergency in their state. And some of them have come off their own state health emergencies. So each state is varying on this.

So the big news here is it’s going to vary by state, it’s going to vary by health plan, and it’s going to vary by account as to whether telehealth is going to continue to be covered and at what rate, at what amount. So you’re going to have to keep checking in with the client’s health plan.

And I know it’s gotten horrible to try to reach anyone in a health plan, much less reach anyone who knows what the heck’s going on at a health plan, and you might get conflicting information. So it’s more frustrating than ever. I know. I sat on a call yesterday for more than an hour, just waiting to talk to someone at one health plan. So I get it.

My first prediction is the first thing that’s going to stop being covered would be phone sessions. And we’ll talk more about Medicare and phone sessions, but I think private health plans will drop that first. So those of you doing phone sessions, I think that is probably the most susceptible.

And that may be because there’s not as much ability to see the client and to be… There could be just more issues in terms of our ability to assess a client over the phone, blah, blah, blah.

So the other concern I have is that a lot of plans are probably going to then stop covering out-of-network providers. This is one way to incentivize people to choose in-network providers where they pay less. And once the pandemic is over, and we’ve already seen this in some plans, that they have stopped covering out-of-network providers and are telling people that you need to come… And we’ll talk more about that later.

I said five predictions. There’s only four there, huh? Oops. Okay. And my biggest concern maybe, or not biggest, but another concern is that some plans may only reimburse you when you are using a certain telehealth platform or group. And when I say that, I’m not talking about using Zoom versus Doxy.me or something like that.

This is them having us register or become part of an online group or a telehealth-providing group like Teladoc or MDLIVE or Amwell. And once we become part of that group, then we could possibly give telehealth to their members.

I got asked to do this and I looked into it, and this was with Blue Cross. They were saying, “Oh, we’re only going to reimburse for this person if you go through Amwell.” And I said, “Well, okay, I’ll look into becoming part of Amwell.” And Amwell said, “Well, we only pay whatever it is.” Let’s say $60.

And I was like, “Wait a minute. This is a Blue Cross client, you’re telling me, Blue Cross, I have to go through Amwell. I have a contract for more than $60 with Blue Cross.” And they said, “Nope. Nope, it’s different.” So my concern is that this may lead to a decrease in reimbursement for us.

Avery Lopez: “Have Medicare and Medicaid covered telehealth and will it continue?” From Jessie J.

6. Have Medicare and Medicaid covered telehealth and will it continue?

Barbara Griswold: All right. Quick review of Medicare. And obviously, by the way, I’m not a Medicare specialist. But just a general overview that in general, as I said before, there’s not going to be any sweeping federal laws that are going to replace state-by-state regulations.

When it comes to telehealth, it’s a state-by-state situation. And they are giving states rights to mandate who can provide telehealth and what’s going to be covered in their state, which is really just unfortunate I think. So the good news about Medicare is they seem to be pretty open to embracing telehealth post-COVID and during COVID actually, so that’s really good news.

In December, for example, they added 60 services to be covered via telehealth beyond the end of the public health emergency, so that was great. They’ve already been thinking past the public health emergency, unlike other insurance plans. But legislation is needed to make telehealth permanent in areas other than rural regions, when the client’s at home or wherever the client is, and to make the coverage of phone sessions permanent. They’ve been covering phone sessions, which is great.

So this legislation is out there, but as far as I know, it has not been passed yet. And there has been a lot of bipartisan support, so I think this is going to happen, so that’s the good news. And that’s why I say, I think in my next little line here, this may be a good time to become or to be a Medicare telehealth provider. I think you’re going to find a lot of support with Medicare.

And what we hope is that the rest of the private plans follow Medicare, however, they don’t always. Now, what about Medicaid? 

I think it’s going to be a state-by-state battle. You’re going to see a wide variety of telehealth coverage in each state. And let’s look at Medicaid. Medicaid coverage varied completely by state, whether they covered phone, whether they didn’t cover phone. So you’re going to have to look up in your state. So this is one of those links I’m going to have on my one-stop shop page.

The CCHP is an organization and they report on Medicaid and private payer coverage in every state. I’m going to put the link for their report on that one-stop shop page, theinsurancemaze.com/TH. And you can click on that and go to your state and find out what the coverage is in each state.

I would say expect more state laws that are going to be coming up for telehealth coverage and payment parody, but you’re going to need to push your state legislator and your professional associations to get behind these bills or to create these bills. We’re going to have to advocate like we’ve never advocated before for telehealth coverage.

Now, in general, I hope the ability to practice across state lines will increase. We’ll be talking about that a little more later, but probably not as easy as you think it’s going to. I think we’re going to see more interstate compacts such as PSYPACT, which is an interstate compact between psychologists; and Counseling Compact, which is one between counselors.

Hopefully, they will grow, allowing telehealth across state lines more frequently; however, they’re growing very, very slowly.

Avery Lopez: “Are there any special telehealth issues for therapists who only issue superbills out-of-network?” From Kalia P.

7. Are there any special telehealth issues for therapists who only issue superbills out-of-network?

Barbara Griswold: Sure. So as I said before, coverage for out-of-network is going to vary by plan and even by client account, so don’t presume that it’s covered. And your clients may presume that too.

And many plans are only covering in-network providers or may only be covering out-of-network temporarily. So the point I want to make on this slide is the next section which is, if the plan says they’re not going to cover, contact them and see if special arrangements can be made because you have been seeing this client and you might want to do a single case agreement, which is basically an agreement that because this person uniquely should be seen by you since they have a previous relationship with you, and so they don’t want to have to start all over again with a new person, and that you can further the treatment plan more quickly, you could make an argument.

Now, whether you should or shouldn’t, this is one of your… Considering a single case agreement, contact me and I can walk you through whether it’s a good idea in your case. It’s also called a network gap exception in a different situation.

Avery Lopez: So the next question here is, “What are the rules about providing therapy to a client in another state? When is it legal? Will insurance cover that?” From Alma O. and Nicolas C.

8. What are the rules about providing therapy to a client in another state? When is it legal? Will insurance cover that?

Barbara Griswold: All right. So this is a big topic, but I think it’s super important that we talk about it because there’s so much misunderstandings out there. So, generally, you must be licensed to practice in the state where the client is at the time of the session, or you must have permission from that state’s licensing board.

It doesn’t matter where your client resides, it doesn’t matter where you reside, it doesn’t matter if they’re going to college in that other… It doesn’t matter if they’re temporarily traveling, blah, blah, blah. It’s kind of easy in a way that it’s just where the client’s feet are at the time of the sessions. Are you licensed there or have you looked into it? And that you have permission to practice there.

This is a big surprise to a lot of you who have been practicing across state lines. And you thought, this is what I hear all the time, “Well, I thought during the pandemic, we can all practice anywhere in the country.” No. Absolutely no. Not all states allow interstate practice, others require registration of some sort, certain conditions, some allow temporary practice. One said I had to get notarized, prove that I was licensed, so it depends on the state. But the state that’s really supervising it is where the client is located.

So do contact the licensing board in that other state, otherwise what you’re doing may be illegal and not covered by your malpractice. Most malpractice will only cover you if you are practicing legally. So as soon as you are doing anything in another state where you are not licensed to practice, and if something happens to that client and you’re sued, you’re not going to be covered by your malpractice in general. I’m speaking very generally here.

So for contact information of state licensing boards and emergency orders, Person-Centered Tech is an organization that you should become aware of if you’re doing anything with HIPAA or anything across state lines. These are my go-to people.

They have put together a 50-state board list and all the emergency orders and just for each… A licensing board in each state. And I’ve put that documentation list, the link to that, again, on my little one-stop shop page, which is theinsurancemaze.com/TH. Get on the Person-Centered Tech mailing list, they’re great people who help therapists with technology issues.

Now, what about if you’ve left the state temporarily? That’s usually not an issue because again, if your client’s feet are still in the state you’re licensed in, that’s usually fine. If you’ve moved out of the state, that’s a different issue which we’re going to talk about quickly later.

Now, here’s the rub, even if you practice illegal, insurance might not cover you. If your client, let’s say, is in New Jersey and you’re in California, it could be that insurance may say, “No, you need to be licensed in both states. It’s not enough to have permission. Or you need to be credentialed in both states. Or you need to be in the same state as the client.”

So insurance plans sometimes have a higher bar than just legal bar. So it’s something that you might want to look into, particularly if it’s going to be an ongoing situation with that client, they didn’t just go on a two-week vacation. And if you move out of the state, you can be terminated from your insurance panel.

I know Blue Cross, many, many people have told me that Blue Cross particularly has terminated them when it became apparent that they moved out of the state. So I think we’re going to talk more about that.

Avery Lopez: So this next question, “Will insurance cover me if I have a telehealth-only practice? Do I need to keep a physical office space even if I work from home?” Cheryl C.

9. Will insurance cover me if I have a telehealth-only practice? Do I need to keep a physical office space even if I work from home?

Barbara Griswold: Yeah. This is a big question. That’s probably one of the biggest questions I’m getting these days in my consultations. So policies vary widely between plans. Some plans like UnitedHealthcare, Optum, what am I thinking? Cigna seems to be pretty good with telehealth-only practices.

There are certain plans that are better and are more supportive I would say of telehealth-only practices and others that don’t. Like I mentioned, Blue Cross seems to be telling providers, at least they told me, “We want all of our folks to have a physical office where they could see clients if needed.”

So some plans are insisting that you have a physical non-home office address, or at least a valid street address for your service location, which is driving a lot of people to maybe come up with locations that aren’t really ones they’re using and giving those to the insurance plans, rightly or wrongly.

Another notation, the NPI Enumerator, those are the folks who give out the national provider IDs. If you go to them and you say, “I need to change my office address because I’ve given up my office,” they do require some kind of physical address. And it’s important to note that that’s a public record.

So if you don’t want to give your home address, which a lot of people don’t. I mean, you don’t want your home address sometimes out there as a public record. And somebody tried getting a UPS address and they told me it was rejected by the NPI enumerator because they could tell it wasn’t a real office address.

P.O. Box is usually not enough, even if that post office box gives you a street address to use. Very often, a P.O. Box would not be enough for an insurance plan to have as a service location.

And using your home address may not be wise because it sometimes will come on your explanation of benefits, which shows how claims were processed, so your clients would see it. Or your statements, again, your clients would see that. It’s just floating out there more, and so it opens you up for the potential for identity theft.

So as I said before, this has led many people to get fake office addresses, ask a colleague to… They might ask a colleague to say, “Can I use your office address as mine?” Or set up some kind of a virtual office address and see if that can work. Also, just consider addresses for your malpractice, your professional license, your city business license, those all need to change also.

Avery Lopez: “What needs to be recorded in the notes for telehealth services?” From Erica H.

10. What needs to be recorded in the notes for telehealth services?

Barbara Griswold: Great question, Erica. All right. So mostly the notes are going to be the same as in-person sessions. And sometimes people are out there saying, “I don’t know that we have to do anything different.” Actually, there’s a few things you do need to do differently with telehealth.

Need to document if the session was video or phone. And here’s one that a lot of us stumble over. Its best practice is to write the client’s location. This is pretty important, to write their location and even their address in… The lawyer that I spoke to said you should write either “client at home” if you have the address in your file, or if the client’s elsewhere, put the exact address, “Client at 12 Main Street, Topeka, Kansas.”

Why? Two reasons. Number one, you’re verifying that the client is in a state that you are licensed in or to practice in. And if not, you want to know that right upfront. So we should be asking our clients every time, “Where are you located?” Unless you see the same two pictures behind them in their bed and you recognize their bedroom. Okay. You can just write “Client at home.”

But I had one situation that I saw a client and she was in her backyard and I said, “Oh, are you in your…” I thought was her backyard. I said, “Are you in your backyard?” And she said, “No, I’m in my aunt’s in Las Vegas.” I was like, “Uh-oh, that’s across state lines.” So asking is really important. So that’s the first reason, so the state line issue.

The other is if she melts down in the middle of the session and signs off, I need to know where to send help. If she was in my office and she melted down, I would be able to intervene right there. But I need to know an address where… You’re going to say, “What if she’s sitting outside of Starbucks in the parking lot and using their wifi? What am I supposed to write down?” You write “Starbucks at the corner of Hamilton and Winchester, San Jose, California.” Again, you just need to know where to send help, and as best as you can, that you try to record the client’s location.

Now, it’s also appropriate or important somewhere, and you don’t have to do this in each session, but that you have assessed the client for their appropriateness for telehealth, and that you decide that they are appropriate. There are some clients who are not appropriate for telehealth due to the severity of their illness or for the need to lay eyes on them to do assessment. So there’s certain clients who I would say we can probably agree are not appropriate for telehealth and need to be seen in person. So you need to document that you have done that assessment.

Also, it’s either mandated by your state law or it’s super important that you have documented some kind of telehealth consent that the client has consented to telehealth sessions and they’ve been informed of the pros and cons of telehealth and any concerns.

And I have heard one occasion, and I don’t know how the claim… A claim was denied because the therapist did not get telehealth consent. Now, I don’t know how common that is out there, but it’s just good practices, it’s a good idea. And having a formal telehealth consent, I think is super important, which is I think the next thing.

So I highly recommend having a telehealth consent. And don’t forget the credit card agreements. Many of us have now shifted over to using credit cards where we weren’t prior to the pandemic. So get a formal credit card agreement about when you can charge the credit card and what situations you can. Are you going to do it before the session? Are you going to do it after the session? How often? Are you going to do it for missed sessions?

So have it laid out so the client understands how you’re going to use their credit card. And again, I have those available for purchase in my practice forms packet, that link is on the one-stop page there.

Avery Lopez: So the next question, “Will reimbursement rates decrease for telehealth sessions?” Judy T.

11. Will reimbursement rates decrease for telehealth sessions?

Barbara Griswold: Yeah. This is a tough question, and it’s going to vary a lot based on what state you’re in. This is a question about payment parity. Is telehealth going to be given equal pay as if you saw the person in person? And there isn’t as much protection out there as you would think to make sure that this happens.

As of January of this year, 43 states and D.C. have some law mandating private payer policy for telehealth coverage. Basically saying, “Hey…” These states are saying, “Hey, if you cover a service for in-person, you need to cover it in telehealth.” So that’s only 43 states, we haven’t even covered the whole country.

But when it comes to that you have to pay the same, I think it’s only seven… You can click now. Let’s see. What do we have here? Only 17 states as of 2020, that number hadn’t been updated when I last looked, mandated payment parity. So that’s a very small number of states were mandating that you’ll have to pay the same for a service.

Now, that doesn’t mean that the health plans weren’t going ahead and paying the same. Many health plans are paying the same. But this is something we need to be working for. Find out the telehealth laws in your state, see that report, CCHP report. I put the link on theinsurancemaze.com/TH for telehealth. And it’ll talk about the payment parity laws in your state. But we need to do a lot of advocacy about this or else, certainly, they could ask for… Pay us less.

Avery Lopez: “So much is unknown for the future. What should we be thinking about?” Katy F.

12. So much is unknown for the future. What should we be thinking about?

Barbara Griswold: So here are some things I just want you guys to start thinking about because I have a feeling, sometimes we’re just thinking two things, (1) that at some point it’s all going to be covered until some point, and then it’s going to all stop being covered. Or no, no, if I had to guess, most people are just thinking telehealth coverage is just going to continue at whatever rate is going on now, from now until the future. And I don’t think that that’s a good way of thinking.

Clients may lose their telehealth coverage and they might lose their coverage without much notice. Communication is so poor these days with insurance plans, I don’t think they’re going to send a notice to all their clients and say, “Hey, you’re going to lose telehealth coverage in three months.”

I don’t think they’re going to send, especially if you’re an out-of-network therapist, I don’t think they’re going to send you an announcement saying, “Hey, your clients are going to lose coverage.” So that’s why it really behooves us to try to check back as often as possible, or have your clients check in about what their coverage is and what’s coming.

And for us to really try to get on the email list for each insurance plan that you work with and get those updates and announcements as much as you can and read them when they come into your email. I know we’re all really busy, but sometimes we just don’t read them.

So I would be saying to each one of my clients, let’s plan as if you’re losing your telehealth coverage. Let’s at least have a conversation. What would we do then? What are your options? Are you able to continue to pay for these services? What would we do? So at least start planning with your clients and have that conversation.

So again, I said you need to check often with plans to get updates because it’s a moving target. I think we’re going to see coverage start to go down.

My recommendation is to bill more often and encourage private pay clients to submit their statements more quickly. That’s the best way we’re going to find out if there’s a problem much more quickly. So if you’re a person who sends in claims once a month, once every two months, once every three months, no. The best way is if you can bill weekly at the very least, or once every two weeks. That way, if they’re not covering something suddenly and you didn’t realize it, you’re not going to be out months and months of payments. Or your clients aren’t going to be not reimbursed for months and months of payments. The small things that you can do is just bill more often.

And as I said, don’t wait. Talk to all your clients now about the possibility of losing the coverage, perhaps suddenly and what their options are, so you’re both prepared and they don’t feel blindsided.

One therapist told me this and I thought I’d throw it in here. She said, “I’m only taking new clients who live nearby, just in case there’s a need to switch to in-person to be covered.” So for her new insurance clients, she said, “I want to make sure I can continue to see them, so I’m not reaching out to people all over the state or accepting people from other parts of the state.” And I thought that was very interesting and forward-thinking. It’s unfortunate, but that’s just another thing to think about.

If you’re practicing across state lines, plan ahead for when the emergency declaration is lifted. When the emergency declaration is lifted, some of these states who are allowing interstate practice may stop and you may no longer be legally able to see those clients in other states.

So plan ahead with your clients to avoid sudden abandonment of your clients or breaking the law. At that point, if it’s illegal then to continue, you are either going… Or planning ahead might include getting licensed in that other state, which several people I know have started to do is just look into getting licensed in that other state. And sometimes it’s a very easy thing to do if you’re already licensed in one state.

Well, we have time for… I’ll say this, we’ll talk about this slide here quickly and then maybe we have time for a few more questions that we put in the hamper in case there were extra time, and then we’ll take some live questions.

But I just want to just talk about some upcoming webinars that we hope you’ll tune in for. One is one that I’m hosting, which is what out-of-network therapists should know about billing. And that will be, again, on my follow-up page, the one-stop-shop page, theinsurancemaze.com/TH. And Avery, did you want to talk about our next webinar with SimplePractice?

Avery Lopez: Yeah. The next one that SimplePractice is sponsoring is the first session, juggling clinical and administrative tasks. And for more information and to get notified when registration opens up, you can also go to theinsurancemaze.com/TH to get more information about that. Moving forward here, we did have some extra… Barbara, do you want to go ahead and mention this one more time?

Barbara Griswold: Yeah. One more time, I just want to say, remember that one-stop shop has the Checking Coverage handout I mentioned earlier, a handout for when you give up your office or practice across state lines. And it’s a checklist that if you’ve given up your office, what to ask the plan. If you’ve moved out of state, what to ask the plan. If your client has left your state, what to ask the plan.

Then it’s going to give you everything you know. So that’s a downloadable, free. All these are freebies. I also have the slide handout, any resources I mentioned today will be on that. The links will be there. And if you have any follow-up questions that weren’t answered today, there’s a form you can just enter them into and I’ll get back to you within, usually, one business day. And then contact information. But we can flip to the extra-time slides.

Avery Lopez: This first question we have here is, “Are insurance plans requiring us to use a HIPAA-compliant telehealth platform?” From Stacy R.

13. Are insurance plans requiring us to use a HIPAA-compliant telehealth platform?

Barbara Griswold: Yeah. Stacy, good question. So just quick overview. Right now, the government is not enforcing the requirement to use a HIPAA-compliant telehealth platform. So usually, before the pandemic, we all were supposed to be using a telehealth platform that was HIPAA-compliant.

Basically, HIPAA is still in place, but they’re looking the other way. They’re saying, “We’re not going to enforce it.” But that may change as the pandemic, as the emergency orders lift. So right now you can use FaceTime, you can use free versions of Zoom and Skype and other things that are not HIPAA-compliant. But we all should be gravitating over to HIPAA-compliant telehealth platforms because they give added security.

Yeah. So we should be using them anyway. And some insurance plans actually are expecting providers to use these compliant platforms, or will be expecting this again soon. I noticed in many health plans they said, “We still expect you to use HIPAA-compliant platforms or require you to use them.”

And basically, the main thing you’re looking for with a HIPAA-compliant platform is that they offer a business associate agreement, also called a BAA, which basically outlines how they will protect you in the case of a data breach. And here, I think the next slide has… Right, is that next?

Avery Lopez: Yeah. I’m trying to…

Barbara Griswold: Has a list of some of the platforms that claim HIPAA compliance. I can’t attest to all of them. Obviously, there’s many that aren’t on here. But these are platforms that say they are HIPAA-compliant. And Zoom is a popular one, but you have to make sure you get a Zoom paid account and make sure you get the BAA. And each one of these should issue you a BAA if you ask for one.

Avery Lopez: Next question, “Are there types of clients for which insurance will not cover telehealth services?” From Stacy R.

14. Are there types of clients for which insurance will not cover telehealth services?

Barbara Griswold: Good question. Yeah. This one is just a stay-here slide. I saw this question and I left it in because I don’t really… I’ve never seen insurance say, “We will not cover telehealth for X, Y, or Z.” It may be that that is out there, but I have never seen a type of client outline like, “We won’t offer it for schizophrenic clients or we won’t offer it for suicidal clients.” So I’ve not seen that. I assume they leave it into your hands to decide which clients may not be clinically appropriate.

15. Prior to the pandemic, did most insurance companies cover telehealth sessions for behavioral health?

Avery Lopez: “Prior to the pandemic, did most insurance companies cover telehealth sessions for behavioral health?” From Kari.

Barbara Griswold: I would say no, at least not in my personal experience. There were a couple of plans that pre-pandemic were pretty positive about it. And again, I mentioned Cigna, I think Magellan, some United Behavioral Health.

But I would say for the most part, in my experience, most of my clients did not have telehealth coverage except it would have to be… It’s going to depend on your state and all that stuff, but sometimes they would cover it if there was no available providers within two hours of the client or if there was no available providers with a specialty that was needed.

So it was usually some… You’d have to prove that they could not provide an in-person provider in the area or that the… They wouldn’t even okay telehealth when a client was laid up, recovering from surgery or things like that. So I hope we’ve really come a long way in that area. But I think it’s going to frustrate all of us that it’s going to be so piecemeal how each state and each insurance plan makes policy decisions about coverage and about payment, and I think it’s going to be very frustrating.

Avery Lopez: I just wanted to thank everybody for coming here. I just wanted to let everybody know that in the follow-up email that’s going out tomorrow, you’re going to get the slides and everything from this whole meeting. Feel free to look into that to review anything. You can always go to Barbara’s website if you want to get more questions answered or anything else. But we appreciate all of you joining us.

Barbara Griswold: What else do we want to say that we didn’t get time for?

16. What else do we want to say that we didn’t get time for?

Avery Lopez: I know while speaking with clinicians, I’ve seen a lot of modifiers, 95 and GT. I thought that only GT was used for only Medicare and everybody else wanted 95.

Barbara Griswold: No, Medicare wants 95.

Avery Lopez: Really? Okay. So one other question we have here is, “Is the BAA just signed by the provider or also each client?”

17. Is the BAA just signed by the provider or also each client?

Barbara Griswold: No, no, no. Not by the clients. No. BAA is an agreement, the Business Associate Agreement is an agreement really between you and the vendor, which in this case would be Zoom or it would be Doxy.me. And Zoom is saying, “Hey, we will provide services for you in these ways. Here’s how we’re going to protect your data.” I’m not even sure I signed my sides of it. I guess I must have. But it’s provided. The clients don’t have anything to do with it.

Avery Lopez: And we got another one here, “If I want to continue to provide services via telehealth, is the featured contract with telehealth companies?”

18. If I want to continue to provide services via telehealth, is the featured contract with telehealth companies?

Barbara Griswold: Well, when they say telehealth companies, I’m not sure if they mean those ones we were talking about like Teladoc or Amwell.

Avery Lopez: Sounds like that’s connected to it, huh?

Barbara Griswold: Yeah. Well, I think that’s something that remains to be seen. Again, whether or not that’s a good deal for you, whether or not you’re going to take a pay cut, whether or not insurance plans… I have that one insurance plan that said you need to go with Amwell. And then I looked into it and it turned out I didn’t need to.

So I think there’s a lot of misinformation being given to representatives. And it’s hard to know what the future’s going to bring in terms of whether they will allow us to keep using whatever telehealth platform we’re using right now or whatever one we want to get lined up with. So I don’t know on that one. I’m taking a wait-and-see approach because they haven’t been clear.

Avery Lopez: So we got another one here. “Are there any issues with clawbacks for out-of-network providers doing telehealth?”

19. Are there any issues with clawbacks for out-of-network providers doing telehealth?

Barbara Griswold: Oh, yes. I just did a whole webinar on audits and records requests, and we talked at length about clawbacks. Clawbacks, basically defining that means, can an insurance company come and ask for money back after they’ve already paid you? And the answer is yes. And it doesn’t matter whether you’re doing telehealth sessions or not.

And I’ve seen it happen a lot lately with United Behavioral Health, Optum, that’s one company, or UnitedHealthcare, and Medicare. Those are the two that seem to be doing some clawbacks recently that are going back up to a year or two of claims that have already been paid, and sometimes asking for your notes. And if your notes are not good enough, they’re asking for your money back.

And you might think you have great notes and you may even have some pretty good notes, but if it doesn’t have X or Y in it, if you don’t state, for example, is the client progressing, or if you don’t cover the medical necessity for treatment, or if you don’t put enough interventions in it, or if your interventions are too general, they may say, “We’re going to take back money from that session.”

It’s really kind of scary and it could happen to out-of-network providers. So that’s one of the things I’m going to talk about in my next webinar. But if you want to know more about this, I have a whole webinar on audits and records requests that goes into this in great detail. Or contact me and I can tell you a little bit about that.

Avery Lopez: Cool. And then we got, “Is it common for insurance companies to request a W-9 nine from the clinician after a client submits a superbill claim?”

20. Is it common for insurance companies to request a W-9 nine from the clinician after a client submits a superbill claim?

Barbara Griswold: Yes. Yes. And people are very scared if you’re an out-of-network clinician and the insurance plan asks you for a W-9 and you think, “Uh-oh, is this me signing up? Are they later going to use it against me in some… Why are they asking for this? They’re not paying me, they’re paying the client.” So there’s all the same questions, but I just want to say, yes, it’s very common for them to ask for a W-9.

You can download one from the internet. You just type in W-9 and look for the IRS site, fill it out and send it to them. And basically, all they’re doing is you are signing and attesting that you are a healthcare entity, your tax ID that’s on the claim or on the superbill is actually what it says it is. So I think it’s just, you get put in their database as legit. So go ahead, don’t hesitate to do that.

Avery Lopez: And then we have one that it sounds like people want a little bit more clarification on is, “If the provider is on vacation out of state, could they still provide telehealth sessions to in-state clients?”

21. If the provider is on vacation out of state, could they still provide telehealth sessions to in-state clients?

Barbara Griswold: Yeah. Remember, I mentioned that if you think about where your client’s feet are, if your client’s feet haven’t gone anywhere, they’re still… Let’s say if you’re a California provider and your client is in California and you go to Hawaii, basically, your client hasn’t moved. You’re still licensed in the state where the client is at the time of the session, so that’s fine.

You just need to be licensed in the state where the client is at the time of the session. That’s usually fine. Again, if you’ve moved, it may be a different situation because the insurance plan may not like you to be in another state, or they may want you to be credentialed in Hawaii.

But for a short period of time, that’s looked on as different. You haven’t changed your provider location. I mean, not your provider location, but your service location. You haven’t given up your office, etc.

Avery Lopez: And we have another one here, this might be the last one. And I actually see this come up too when I’m talking to clinicians here at SimplePractice. It says, “Does the telehealth consent form have to be renewed yearly?”

22. Does the telehealth consent form have to be renewed yearly?

Barbara Griswold: That may be more of a legal question than I want to… That may vary with your state. Each state requires different things about informed consent. In some states, it only needs to be verbally done at this point. I still recommend that you have it in writing. Whether it needs to be renewed yearly might be a state-by-state answer. So definitely ask the attorneys or the professional association in your state. I would guess not, but I don’t want to give you bad advice.

Avery Lopez: All right. Well, with that, I think I just want to, again, thank everybody for coming. I hope everything we gave you guys here was useful and you can use it going forward. And then again, you can always go to Barbara’s website to get any information and all of the stuff she supplies you with. So, everybody, take care and we will see you next time.