Novel Reimbursement Opportunities Await

Opportunities to impact reimbursement are not typical for patient access leaders, but the Medicare Physician Fee Schedule Final Rule may change that outlook. As of January 1, 2024, there are confirmed payments on behalf of Medicare beneficiaries for:

1. Care navigation. Through the new “principal illness navigation” codes (G0023, G0024, G0140, and G0146), billable services include identifying and connecting patients with appropriate support resources. The codes are designed to be used for high-risk conditions such as dementia and cancer.
2. Social determinants of health (SDOH). Screening for SDOH is now included as a reimbursable service. Using code G0136, practices can administer the payable screening with no patient cost-sharing. The government is not requiring a specific screening, but suggests several to consider including PRAPARE.
3. Caregiver training. Physicians and advanced practice providers are paid to train caregivers in order to carry out a treatment plan. Therapists and clinical psychologists are also eligible providers. Codes include 96202, 96203, 97550, 97551, and 97552.
4. Community engagement. For arranging services that extend to the community, practices can be paid for efforts to assist patients through Community Health Integration with new codes G0019 and G0022.

For access leaders engaged in efforts to deploy telemedicine, the government codifies permanent reimbursement for certain services. Further, the Final Rule confirms the higher, non-facility rate will be paid for telemedicine services billed with the site of service as 10 – Telehealth Provided in Patient’s Home. This contrasts to the lower rate if billed under 02 – Telehealth Provided Other than in Patient’s Home. It’s an opportune to confirm that these telemedicine services are being billed correctly.

For (lots) more information, check out the Final Rule.

Although the government’s ruling relates to Medicare exclusively, decisions from the Centers for Medicare & Medicaid Services set a precedent for reimbursement trends.