Will the Expansion of Telehealth Services Lead to More Conditional Payments?

CMS, Conditional Payments, Medicare Set-Aside Blog, Telehealth on March 30, 2020
Posted by Jean S. Goldstein, JD, CMSP

In 2019, Medicare started covering some virtual care services. The services covered included brief communications and Virtual Check-Ins (short patient-initiated communications with a healthcare practitioner) along with E-visits (which are non-face-to-face patient-initiated communications through an online patient portal). However, telehealth services have generally not been covered. Historically, for telehealth services to be covered, certain circumstances would need to apply.  For example, if the beneficiary lived in a rural area; and even then, travel to a local medical facility for telehealth services from a doctor in another remote location was often required, and the beneficiary generally could not get telehealth services in their home. That was until earlier this month when the Centers for Medicare & Medicaid Services (CMS) lifted these restrictions and announced that it was broadening access to Medicare telehealth services in an effort to ensure that Medicare beneficiaries can get a wider range of services from medical providers without traveling to a health care facility. The expanded coverage allows for telehealth services, regardless of where the beneficiary resides, and in any health care facility including a physician’s office, hospital, nursing home or rural health clinic, as well as from a beneficiary’s home. The specific set of services covered under Medicare’s broadened coverage includes evaluations and management visits (common office visits), mental health counseling, and preventive health screenings, without regard to a beneficiary’s diagnosis

Lifting the prior coverage restrictions is certainly a justified modification, with growing concerns of transmission of the Coronavirus to beneficiaries. Nonetheless from a claims management perspective, primary payers [1] may need to be on alert for conditional payments that could result from this broadened coverage. A conditional payment occurs when Medicare makes a payment for services another payer may be responsible for, or in instances where the primary payer does not pay promptly. If Medicare beneficiaries are now seeing physicians, nurse practitioners, and clinical psychologists for routine visits through telehealth, there is a possibility that conditional payments will be made on a claim or body part for which a primary payer is responsible for.  Moreover, given that many carriers and law firms have moved to remote work, there may be considerable delays in obtaining billing invoices affiliated with telehealth services and conditional payments. Therefore, during this time as many payers are navigating uncharted waters, we would offer the following tips: 

  1. Create an open dialogue now between the parties to coordinate and identify treatment in the coming weeks. Do not assume that beneficiaries are not treating because bills have not been received. Ask questions of beneficiaries as to whether they are still treating or have utilized telehealth services.
  2. Review your processes on how to timely handle conditional payments, Medicare Advantage Plan recoveries, and other liens. Remember that conditional payments are not just made by Medicare, but also can be made by Medicare Advantage Plans, Group Health Plans, Medicaid, and the Department of Veterans Affairs.  Also, it is important to understand that your own internal workflows may have shifted during this unprecedented time. It is beneficial to review whether conditional payment notices and demands are being received and documented in the same manner, through the same mail collection processes.  Revisiting these workflows may make the difference as to whether penalties and interest associated with conditional payments are incurred.  With workflows having changed quite significantly over the last several weeks, and the possibility of increased recovery efforts on the horizon, this may an opportune time to consider designating a Recovery Agent.  A Recovery Agent is an entity or organization that will receive, directly from the CMS contractor, copies of all conditional payment recovery correspondence associated with an applicable plan.  Designating a Recovery Agent ensures that a named agent will receive all conditional payment recovery correspondence automatically, and therefore be able to timely, and efficiently respond to all recovery efforts within the required time frames, prior to claims being entered into the demand status.
  3. Continue to diligently review, negotiate and resolve all conditional payments. Of significant note, in a recent teleconference held by CMS, CMS addressed specific challenges with the “grouper algorithm” which is used to identify Medicare payments that are related to a case or condition for which a primary payer is responsible. In this teleconference, CMS acknowledged that the algorithm has in many instances grouped charges that are unrelated and attributed those charges as conditional payments for which reimbursement was requested from a primary payer. While CMS also indicated that an outside contractor was reviewing and addressing the current challenges associated with the algorithm, it is important to consider the possible impact of telehealth coverage being expanded. This expansion may result in additional unrelated conditional payments being identified under the grouper algorithm as beneficiaries call upon more service providers virtually. Therefore, it is more important than ever to be diligent in reviewing and disputing conditional payments.

While telehealth is providing greater access and care to beneficiaries during this challenging time, primary payers should nonetheless ensure that proactive practices to address conditional payments are in place to continue to best position claims for resolution.


MEDVAL offers assistance with conditional payments and lien resolutions.  We are also a designated Recovery Agent for many of our clients and welcome the opportunity to further discuss how we can assist you during this unprecedented time.  Our Medicare Secondary Payer Compliance Team is also available to assist with implementing best practices and compliance protocols.  Please be sure to keep checking our blog, or please feel free to reach out to a member of our team either at info@medval.com, or (410) 740-3084 if we can be of assistance.


[1]  Primary payers include, but are not limited to insurers, or self-insurers, third-party administrators, and all employers that sponsor or contribute to group health plans or large group health plans. See 42 C.F.R. § 411.21.