Telehealth Billing Policy Awareness for Nurse Practitioners
When rendering telehealth care, NPs must be aware of billing policies for BOTH the state where the patient is located AND the patient's insurance company. The correct answers are: (1) be aware of appropriate billing policies for the state that the patient is located in, and (3) be aware of the appropriate billing policies for the patient's insurance company.
Why Patient Location State Matters Most
Telehealth is legally understood to occur at the patient's location for regulatory purposes, making the patient's state the primary jurisdiction governing billing policies. 1 This fundamental principle drives all downstream billing requirements:
Providers must observe local laws in the state where the patient is located at the time of the telehealth encounter. 1 This is not optional—it's a regulatory requirement that supersedes where the NP is physically located.
Telehealth payment policies vary dramatically at the state level, with each state having different Medicaid reimbursement structures, commercial payer mandates, and coverage requirements. 1 The American Academy of Pediatrics explicitly states "it is essential that pediatricians understand Medicaid and commercial-payer policies in the state(s) in which they practice." 1
42 states plus the District of Columbia mandate commercial insurer coverage for telehealth services, but these mandates only apply to plans originating in their state. 1 Out-of-state commercial plans and ERISA plans may not be subject to these state mandates, creating additional complexity. 1
Why Insurance Company Policies Are Critical
Insurance coverage for telehealth services varies widely even within the same state, making knowledge of specific payer policies essential for reimbursement. 2, 3
Commercial insurance plans have diverse restrictions and requirements that differ from both Medicare and Medicaid policies. 4 Some plans voluntarily cover telehealth services while others do not, regardless of state mandates. 5
Medicare has specific CPT code requirements (99201-99205 for new patients, 99211-99215 for established patients, with modifier 95 for telemedicine delivery) that differ from some commercial payers. 2 Understanding these payer-specific coding requirements is necessary to secure reimbursement.
Payment parity is not universal—while some states require insurers to reimburse telehealth at the same rate as in-person services, many do not. 1 Only 13 states require Medicaid to reimburse live video "consistent with" or at the "same rate" as in-person services. 4
Why NP Location State Is NOT the Answer
The state where the NP is located is not the determining factor for billing policies in telehealth encounters. 1 While NPs must maintain licensure in the patient's state (not just their own), billing policies follow the patient's location and their specific insurance plan requirements. 1, 2
Practical Implementation Strategy
To avoid billing denials and compliance issues:
Verify patient location at the start of each telehealth encounter and confirm you understand that state's specific telehealth reimbursement policies. 2
Check the patient's insurance plan coverage for telehealth services before the visit, as coverage varies even among plans from the same insurer. 2, 5
Consult the Center for Connected Health Policy website for state-by-state policy information, as recommended by the American Academy of Pediatrics. 1, 2
Be aware that COVID-19 public health emergency waivers may expire, potentially eliminating expanded coverage that temporarily mirrored Medicare's relaxed restrictions. 1 Recheck policies regularly, particularly when PHE waivers with variable expiration dates are in effect. 1
Common Pitfalls to Avoid
Assuming state mandates apply to all insurance plans—ERISA plans and out-of-state commercial plans may not be subject to the patient's state telehealth mandates. 1
Failing to verify real-time interactive audio-video requirements—modifier 95 requires both audio and video; audio-only visits may not qualify for reimbursement under many policies. 2
Neglecting to append modifier 95 to telehealth CPT codes, which is required to indicate telemedicine delivery for most payers. 2