Telehealth Risk Adjustment by Line of Business

Written by Ted Kyi

May 5, 2020

I know I have focused on Medicare Advantage in my posts here, which is a reflection of both the size of the risk adjustment market for MA, as well as the lack of clarity about risk adjustment which had surrounded MA.  Here is a recap of how telehealth visits can be used for risk adjustment by line of business:

Medicare Advantage – telehealth is allowed, requires video with audio for diagnoses to count toward risk adjustment

ACA commercial – telehealth allowed, state regulation of the practice of medicine determines allowed modalities (audio-only or video)

Medicaid – regulation delegated to the states, so also state-by-state which modalities allowed.  Note that Medicaid regulations about telehealth aren’t always the same as the regulations that govern ACA in the same state. For example, in Georgia, “standard telephone” calls do not constitute telemedicine services, but the Georgia Medicaid waiver explicitly allows telephone communication.

CMS has extended section 1135 waivers for many states, allowing them to relax rules during the public health emergency.  These waivers cover expanded use of telehealth, reduced cost sharing, as well as extending out of state license reciprocity.  Three great resources for tracking the individual state regulations on licensure and telehealth regulations are:

National Council of State Boards of Nursing (NCSBN)

Federation of State Medical Boards (FSMB)

Center for Connected Health Policy (CCHP)

You should also refer to the CMS website for the list of approved state waivers.

Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.