Reimbursement for Teleconsultation by health insurance companies : A story from the USA By Dr. Pramod K Gaur, Formerly VP, United Health Insurance Adjunct Professor, Seidenberg School of CS & IS, Pace University, USA

1. 1
IMPACT OF HEALTH INSURANCE AND
GOVERNMENT REIMBURSEMENT EXPANSION
ON VIRTUAL VISIT TELEMEDICINE MARKET,
THE USA PERSPECTIVE
Pramod K. Gaur Ph.D.
Adjunct Professor, Pace University
Chair, mHealth SIG, American Telemedicine Association

2. 2
Key Stakeholders for Scalable and Sustainable Telehealth Program

3. 3
Wellness and
Prevention Care
Chronic Disease
End Of Life Care
Acute and
Sub-Acute Care
TPM Goal
Improve
Overall Health
and Wellbeing
Stay
Healthy
Get
Healthy
Living with
Illness
Mobile Health Apps
Evidence Based
Telemedicine
Remote Patient
Monitoring
75%
20% 5%
Reimbursement for TPM Services

4. 1. Federal Government – Medicare
• Traditional Medicare
• Managed Medicare
• DoD/VA
2. State Governments – Medicaid
• Traditional Medicaid
• Managed Medicare
• Medicaid - Medicare Dual Eligible
3. Large Employers – Self Insured
• Over 90% plans have Telehealth Coverage Now
4. Insurance Companies
• Risk Based Policies for Individuals and Small
Businesses Provide Telehealth Coverage
5. Self Pay – Consumers can get a Teleconsult for $49
Telehealth Reimbursement: PAYERS
4

5. 1. Traditional Fee for Service
2. Capitated/Negotiated Rates
• ACO
• PCMH
• Bundle Payment
• Episode of Care
3. Employer Wellness/Prevention Incentives
4. Pre-Tax Spending Accounts
• Health Savings Account
• Flexible Savings Account
5. Self Pay - High Deductible Plans
PAYERS: Reimbursement Models

6. 6
PAYERS: Reimbursement Models

7. 7
PAYERS: Latest Reimbursement News
Aetna Enters Into Agreement to Provide Value-Based Care
Cigna Telehealth Connection Expands Access and Choice to Millions
Including Adding Access to Behavioral Health Consults
United Healthcare Offers Compelling Medicare Products for 2017
Aetna to Transform Members’ Consumer Health Experience Using
iPhone, iPad and Apple Watch
Telehealth Visits covered by 29 Blue Cross Blue Shield Plans
UPMC launches telehealth startup to keep nursing home patients
out of the hospital
More Than Half of Kaiser Permanente's Patient Visits Are Done Virtually

8. 8
QUESTIONS