When Cleveland Clinic said it would begin billing for certain Epic MyChart messages this November, it set off a fiery debate across the healthcare industry around hospital finances, patient access and physician burnout.
Now at least seven other health systems nationwide have also started billing patients for some types of messages sent over patient portals, including those about new symptoms, prescription issues, and those that require extensive time from a clinician to review a patient's medical history.
"Hospitals have every incentive to be creative in generating any cash they can," Ge Bai, PhD, professor of accounting and health policy at Johns Hopkins University, told Becker's. "In general, systems are going to find every single opportunity to charge more. It's like milking the cow."
But what's more uncertain is how long Medicare will cover these charges and whether most commercial insurers will end up reimbursing for them at all.
How will payers respond?
On Nov. 15, Cleveland Clinic said most insurers would cover charges for MyChart messages "at little to no cost to the patient," though it's likely that coverage policies will be fragmented across payers.
"The provider gets the money, so the payers are being blindfolded and they have very little skin in the game," Dr. Bai said. "That makes them not very nimble and low response players."
In 2022, she predicts that self-insured employers will mostly pass the cost of portal messages along to employees. A small number of payers could act proactively to prevent charges this year, especially those operating in the most competitive premiums markets.
Next year, Dr. Bai expects the price tag of patient portal messages for commercially insured patients to become like most other healthcare services — dependent on the health plan and negotiated between payers and providers.
"You pay, but you are not the person who negotiates that," Dr. Bai said. "Even the most sophisticated and well informed consumers have their hands tied."
At Cleveland Clinic, patients with a deductible (over half of private-sector Americans in 2020) and those without insurance (26.4 million people in 2022) face charges of up to $50. A spokesperson for Ohio State University Wexner Medical Center in Columbus told cleveland.com that some patients could face charges of up to $160.
"Many messages sent through MyChart are never billed to insurance," Providence wrote in a MyChart FAQ. "However, those that require time and expertise are a form of virtual care and are treated as such — alongside other types of care.”
Out-of-pocket costs for Medicare members are expected to range from about $3 to $10, depending on the health system.
Commercial payers will also likely wait to see how Medicare policies develop around this issue because they may be shaped by the end of the COVID-19 public health emergency, which won't occur until at least next spring.
Becker's asked UnitedHealthcare, Aetna, Cigna and Health Care Service Corp. (BCBS) how they are developing coverage policies around patient portal messages, but did not receive any responses.
Long-term billing outlook
In 2020, Current Procedural Terminology, or CPT, codes were rolled out to allow for providers to report and bill for patient portal messages.
Under a current rule from CMS, patient portal codes would remain past the PHE expiration date. But according to Terry Fletcher, a healthcare coding and reimbursement consultant, there's been no published final guidance from CMS confirming that the codes won't be rolled back to non-payable status once the PHE has been over for 151 days. Patient portals are not necessarily considered "telehealth," she said, meaning the Advancing Telehealth Beyond COVID-19 Act would not preserve coverage under Medicare either.
"We anticipate this [codes] is going to be rolled back once the PHE ends and at the end of the Consolidated Appropriations Act," Ms. Fletcher told Becker's. "Patients are mostly accessing this, from what I'm hearing, because they can't get an appointment, not because they want the information."
Her Laguna Niguel, Calif.-based consulting firm has advised some of the nation's largest health systems on their coding and billing practices. She's concerned some systems will face audit issues with charging for patient portal messages because of the strict coding rules in place.
"Where there may be a problem reporting this service to payers, is that there are entities that say they can put out "general information" to their patients to the portal, and then charge for it. They can't, and as an auditor myself, I would have a field day with it," she said. "There are specific rules that are attached to EMR portal e-visits, and even though I can see the appeal of capture, there's actually more, in my opinion, that can expose providers to an audit than could help them with revenue if not compliant."
Physicians and other qualified healthcare professionals can bill patients for cumulative work done over a seven-day period that takes a minimum of five minutes or more. If the patient was seen for an office visit within 7-days of the initiation of the online digital visit, the service is included in the face-to-face encounter and cannot be billed. The clock on the seven days starts ticking with the review of the patient's inquiry, and patients must provide consent to be charged for the service.
Ms. Fletcher said there's already scrutiny from CMS around the practice of virtual services, and she expects it to continue.
"This is what we call low-hanging fruit because it's not face to face and it has to be patient initiated," she said. "Plus there's the seven-day accumulation, and doctors are not always compliant in documenting time in their records, for time-based codes."
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