Remote second opinions (RSOs) connect patients with specialists via virtual modalities and gather relevant clinical information without the need for in-person visits—and amid Covid-19, when arranging in-person visits is more difficult, RSOs are more important than ever. However, reimbursement for these services has historically been a challenge.
Given that payers have not settled on decisions around reimbursement, we listed out top FAQs to help your team navigate the uncertainty and expose some of the myths behind RSO reimbursement.
1. Do payers reimburse for RSOs?
Most private and public health plans cover only in-person second opinion consultations, not online second opinion consultations. This means that once the patient or local provider starts an RSO, the provider—with or without the RSO company—will compile the documents needed for review, and the assigned specialist will bill the patient directly for the services. Specialists are not able to file a claim with insurance carriers, nor supply a procedure code (CPT) for the RSO, unless this is deemed a covered telehealth visit. Federal and state policies also limit how telehealth and RSO services are delivered and reimbursed, which means that regulations can vary across public and commercial payers and across state lines.
2. How much do patients pay out-of-pocket for RSOs?
RSOs typically range anywhere between $750 and $2,500. The price variability is mostly dependent on the provider and subspecialty, and from fees associated with follow-up appointments, secondary imaging reads, and specialized pathology reviews. Providers can encourage patients to check with their insurance for full details on their coverage for RSOs—their Health Savings Account (HSA) and Flex Spending Account (FSA) might cover some of the cost. Regardless, patients are willing to pay out-of-pocket for RSOs, and there is a growing number of nonprofits that are helping to fill the reimbursement gap for RSOs.
3. How can providers encourage payers to cover RSOs?
The first major way providers and RSO companies can navigate the gray areas surrounding RSO reimbursement is to determine whether any of the procedures are covered telehealth visits. They then should review the local regulatory landscape and advocate for change to close access barriers where possible—especially for disadvantaged populations.
Learn about the current telehealth policies in your state, including the reimbursement eligibility criteria and practice standards that govern RSO delivery. From there, collaborate with key stakeholders on advocacy efforts. These efforts may include helping patients obtain devices, such as tablets or phones, aiding digital literacy through tutorials or trainings, and supporting broadband connection and reimbursement parity—namely, paying the same rate for a virtual visit as an in-person visit.
Additionally, providers and RSO companies should develop methods to collect data and evaluate outcomes, since not all telehealth services are created equal. Currently, payers worry that telehealth will increase utilization, so tracking data on RSOs will help support advocacy efforts. For instance, RSOs can lead to better care by replacing patient consultations that do not require in-person visits and supplement them by collecting and consolidating patient records. This is particularly helpful for remote expert consultations in areas with limited access to specialists.
Regardless, collecting data on the process and outcomes will help payers make informed decisions regarding RSO coverage options. Below we have listed a few stakeholder considerations:
- Do payers in my state reimburse telehealth?
- What are the gaps in the current policies and what are the policy targets for my state?
- What is the reimbursement eligibility criteria?
- What metrics do providers look for to track patient experience for virtual visits?
- Who are the state collaboratives or local networks I should contact?
4. What is the outlook of RSO reimbursement?
Clearly, Covid-19 caused a massive uptick in consumer experience with, and exposure to, telehealth and virtual care services. The federal CARES Act lifted restrictions for the duration of the pandemic, and CMS and Medicare now reimburse many telehealth services at the same rate for a virtual visit as an in-person visit. Although telehealth usage has dropped, it is still higher than pre-pandemic levels. This momentum could accelerate reimbursement and coverage decisions for differentiated forms of telehealth tools, such as RSOs. RSOs are particularly primed for reimbursement, since they go beyond the digital substitution of patient visits by collecting and consolidating relevant clinical information to support on-going care coordination and care management efforts.
Although most public and private plans recognize that clarity around RSO reimbursement is needed moving forward, it will be a waiting game until they make final decisions about what they will change in their policies.
Learn more: Remote Second Opinions 101
Second opinions can be valuable to clinicians and patients looking for diagnosis confirmation or weighing treatment options. But in-person access to specialists and expert consultations is limited and often inconvenient, especially outside of major metropolitan areas. In these unprecedented times, when patients are reluctant to seek in-person care, remote access to specialist expertise is more important than ever.
In this cheat sheet, we review RSOs, why they matter, how they work, present barriers to success, and conversations that you should be having before implementing an RSO solution.