More and more health systems are asking for compensation for services provided by physicians through patient portals such as MyChart, raising questions among payers about the downstream impact on costs.
The Cleveland Clinic in Ohio this month began charging patients for certain MyChart messages with providers, such as responses that require “medical expertise…typically taking five minutes or more for your provider to respond.” This includes conversations about medication changes, new symptoms, or chronic health checkups. Last month, NorthShore University HealthSystem in Evanston, Illinois, also began charging for certain messages sent through its patient portal, NorthShoreConnect. And Cleveland University Hospitals is considering charging for messages that require clinicians to review patient records, conduct research or undertake additional communications.
Physicians have long resisted engaging with patients by phone, email, and other means of communication that replace or supplement in-person visits, largely because they typically weren’t paid for their time. But emerging technologies, changing patient preferences, and the influence of the COVID-19 pandemic have made email more appealing to patients and a lucrative opportunity for providers.
As the use of telehealth grows, doctors say they are inundated with email messages from patients seeking additional help that goes beyond regular appointments. As a result, some health systems require payers to provide reimbursements that will support provider-patient communications. Message billing is likely to become more common in the near term, in part due to convenience and growing consumer preferences for certain virtual health services.
“Time has to be paid for by someone,” said Chip Kahn, president and CEO of the American Hospital Federation. “We now have a lot of different channels of communication. Patients and clinicians will want to take advantage of all these possibilities. For payers, to ignore this is to ignore communication, which is truly critical to patient care.
A key precursor to messaging was the implementation of electronic health records with patient portals, such as Epic Systems’ MyChart, which evolved into messaging platforms. The Centers for Medicare and Medicaid Services have developed billing codes doctors can use to get Medicare payments for “virtual check-ins” and “electronic visits.” CMS limits the frequency of use of these codes and imposes standards on the necessary time spent answering patient questions and what types of communications are eligible for reimbursement.
Most clinicians did not use these codes before the pandemic because telemedicine was rare. In addition, government and health insurers were concerned about fraud and overuse of telehealth, said Jennifer Breuer, co-chair of law firm Faegre Drinker’s digital health practice group. “CMS’s fear has always been, frankly, that bored little old women will call their doctors too often,” she said.
As the pandemic overwhelmed hospitals and closed other types of healthcare facilities in 2020, the use of telehealth exploded. While this partly solves access issues, it has also exacerbated physician burnout, especially among women.
Messaging demand has doubled at the Cleveland Clinic since 2019, and providers are spending a significant amount of time responding to hundreds of messages each week, a spokesperson said. UCHealth saw the number of messages triple to about 183,000 per month, said Dr. CT Lin, director of medical information for the Aurora, Colo.-based health system.
“You would think that the pandemic taking hold would mean the numbers would go down. No. Patients have found a new channel and they love it,” Lin said.
Health systems adopting messaging capabilities complement a broader move away from inpatient services. Courier is also an increasingly popular choice among patients on high-deductible plans looking to save money by avoiding office visits.
A year ago, University of California San Francisco Health began billing for medical advice through MyChart. Fees range from nothing for Medicaid recipients at $20 copay for Medicare Advantage members to an average of $75 for those with private insurance. Cleveland Clinic fees range from $3 for those enrolled in Medicare up to $50 for privately insured patients.
Because those amounts are small, payment disputes between insurers and providers are unlikely to trigger full-fledged contract fights, Breuer said. But insurers are expected to conduct regular audits of telehealth usage, especially with providers who frequently charge for messaging, she said. If providers don’t keep documentation showing the medical necessity of a service, insurers will withhold payment, she said.
“There is still some trepidation among payers who want to ensure telemedicine is used wisely and appropriately,” Breuer said. “It’s the balancing act.”
The AHIP health insurance trade group did not respond to an interview request. The Alliance of Community Health Plans, which represents nonprofit insurers, said paying for messages from providers has not been an issue for its members and declined to comment further.
Private health insurers tend to follow CMS’s lead in reimbursement policy. Still, it could take insurers and providers years to establish clear and consistent coding rules, said Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research.
These new coding and billing protocols could create even more administrative burden for providers, especially for smaller businesses with fewer resources. To stay competitive, healthcare systems need to invest in better technology for their patient portals.
“I totally understand where the vendors are coming from, and I think something needs to be done to get them paid for their efforts,” said Chris George, senior managing director at FTI Consulting. “You’ll see it grow over time, but what can’t continue to happen is that patients contact the provider and a response takes forever, and that’s because [of] the … volume of requests that arrive through these different channels.
Health systems say most claims are processed quickly and are not billed to insurance. Messages to schedule appointments, renew prescriptions or answer post-procedure follow-up questions are always free. In some cases, billable messages can replace scheduled virtual or in-person appointments.
Billing for messages could even become a promotional opportunity. For example, an insurer may advertise that it covers the cost of certain types of interactions that its rivals do not in order to attract new customers. Healthcare systems could also be losing patients because of the messages they charge for. “We could actually see some really interesting competitive developments here in terms of competition between clinicians,” Young said. “You can see the TV commercials and the billboards.”
The implications of this emerging trend for access and cost are difficult to predict, said JoAnn Volk, co-director of the Georgetown University Center for Health Insurance Reforms.
Hitting patients with bills could deter some from seeking care, Volk said. Others may be willing to pay for the messages to avoid long waits at urgent care facilities. And the confusion over courier fees could have legal ramifications. In Washington State, for example, providers must inform patients if they intend to charge for a phone call and obtain their consent before proceeding with the audio visit. Otherwise, they could face fines or other disciplinary action from state regulators.
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