Remote patient monitoring (RPM) is an important technology for managing chronic conditions and improving patient outcomes. However, reimbursement and coverage of remote patient monitoring by private insurance plans have been challenging. This article highlights remote patient monitoring private insurance key takeaways from the insightful Future of Health report released by The American Medical Association (AMA) and Manatt Health. It also provides insights into the current healthcare landscape, emerging trends, and the obstacles associated with adopting digital health within commercial health plans.
The AMA report gives an in-depth look at private insurance coverage and reimbursement trends for digital medicine. AMA and Manatt Health asked the plans to validate policies and supply changes. Six private insurers did not respond. The 16 commercial private insurance plans listed in the report were as follows: Aetna, Blue Cross Blue Shield of Illinois, Massachusetts, Michigan, North Carolina, Texas, and California, CareFirst Blue Cross Blue Shield, Cigna, Elevance Health, Florida Blue, Highmark Blue Shield, Horizon Blue Cross Blue Shield of New Jersey, Regence, Tufts Health Plan, and UnitedHealth Group.
Slow Adoption of Remote Patient Monitoring Among Private Insurers
The digital medicine billing codes analyzed for the commercial private insurers include RPM, remote therapeutic monitoring (RTM), eConsults, and eVisits. Coverage for each code was categorized as to whether the private insurance payer fully validated it, validated it with limitations or unique terms, did not cover it, or directed providers to use a different code for telehealth services.
The RPM and RTM codes spanned initial setup, device supply, data transmission, care management, and self-measured blood pressure. Common coverage limitations across private insurers included restricting use to specific conditions, enforcing frequency caps, codes that are not currently covered but expected to be by fall 2023, and temporary coverage available through the end of 2023.
More specifically, the AMA report highlights that traditional Medicare and Medicare Advantage plans cover all 21 digital medicine services examined. However, the 16 private health insurance plans offered through Medicare Advantage do not provide that same comprehensive remote patient monitoring private insurance coverage in their commercial market offerings outside of Medicare.
Medicare vs. Private Insurance Remote Patient Monitoring Coverage
Typically, insurance companies review new CPT codes and make coverage decisions by committee. They consider factors like Medicare coverage policies and clinical evidence. Some states have rules about what private insurers must cover, which can supersede the insurer’s policies.
Private insurers tend to take cues from Medicare on what services to cover, but they do not always follow Medicare’s coverage decisions exactly. Furthermore, the data in the report spotlights the discrepancy in RPM coverage between public and private payers. While Medicare has expanded access to RPM CPT codes over the past few years, private insurance coverage for remote patient monitoring remains inconsistent and more limited compared to public payers like Medicare and Medicaid.
Key Obstacles to Commercial Private Insurance Coverage
Medicaid RPM coverage is more limited than Medicare currently, though it has been steadily expanding over time as well. Expanding digital medicine private insurance coverage could help drive better health outcomes and cost savings for members. In this section, we outline the key challenges in commercial private insurance coverage of remote patient monitoring. These key takeaways apply to healthcare professionals, policy-makers, and industry stakeholders seeking an understanding of the current state of RPM coverage and its implications for patient care and the healthcare system.
Lack of Coverage Alignment
As mentioned, a major issue identified is the lack of alignment between Medicare, Medicaid, and private insurers regarding RPM coverage. For example, Medicare covers RPM for a broader range of conditions compared to limitations imposed by some private plans. This lack of consistency makes it difficult for providers to offer RPM reliably and confuses patients about what services may be accessible through private insurance.
The AMA report calls for expanded private insurance coverage and increased transparency around reimbursement policies to help address this alignment problem.
Slow Adoption of RPM Codes
The AMA report also underscored the slow adoption of newly developed CPT codes for RPM among commercial private insurance plans. Although the codes were created to support RPM services, most private insurers have been slow to add them to their fee schedules. While some plans cover a subset of RPM codes, others do not cover certain services. Very few currently reimburse for the full range of RPM codes.
This data indicates remote patient monitoring private insurers have room for improvement when adopting standard codes for emerging technologies like RPM.
Limited Transparency into Coverage
In addition, a lack of publicly available information on private insurance coverage policies adds to the confusion. Based on analyzing these 16 major private insurers, the AMA report found commercial coverage transparency highly variable. Some plans have detailed clinical policies available, while many others provide little or outdated details.
This lack of transparency confuses providers about whether RPM will be covered by private insurance. The report recommends private insurers increase visibility into their RPM coverage and reimbursement policies.
Strict Requirements Impacting Adoption
Even when private insurance plans cover RPM codes, stringent requirements can limit real-world provider adoption. For example, payers may impose specific monitoring protocols or only cover RPM for certain conditions. In contrast, Medicare has fewer restrictions on clinical use cases for RPM coverage. According to the report, these stricter commercial requirements have lowered RPM claims volume despite the technology’s many benefits.
The Future and Remote Patient Monitoring Private Insurance Coverage
While the AMA report shows positive momentum, it highlights the need for expanded evidence, education, and engagement around digital medicine to drive better commercial private insurance coverage and utilization. Wider adoption and optimization of RPM face obstacles but could steadily increase as payers recognize the technology’s value in improving outcomes and lowering costs.
Medicare has taken a lead role in expanding access, reducing barriers, and encouraging utilization of RPM for chronically ill patients. Private insurers have been slower to cover RPM and impose more restrictions when they do. The Future of Health report provides an excellent overview of where reimbursement currently stands among private insurance payers in the U.S. It’s a must-read for anyone involved in the remote monitoring and digital health space.
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