Does your health plan’s
coverage align with your
digital medicine philosophy?

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A recent brief on the future of health published by the American Medical Association (AMA) in 2023ⁱ found a large discrepancy in the coverages of digital medicine services across the commercial health plan marketplace..

With increased utilization of digital medicine solutions over the last decade, the AMA, in conjunction with other agencies, created over 20 digital medicine CPTⁱⁱ codes for various telephone/internet consultations and remote patient monitoring. These codes became effective from 2019 – 2022, however coverage of these codes continues to vary widely between Medicare, Medicaid and among commercial payors.

Whether you are in the early stages of exploring point solutions, or have already implemented one or more, the central question is: Does the point solution deliver a return on your investment in either elevating the patient care experience, favorably impacting medical spend or increasing employee productivity?

The variability in coverage coupled with a lack in coverage transparency makes it almost impossible for your employees to understand their benefits. Doctors who deal with multiple payors are also becoming confused with what digital health services are or are not covered and are unable to direct their patients toward the highest value care.

For example, the AMA brief found that while some payers did not cover these codes at all, others would only pay in the case of specific indications (e.g., heart failure, chronic obstructive pulmonary disease, COVID-19, or high blood pressure), or exclude coverage for specific categories like asynchronous communication.

1. Understand what services are covered and if there are any specific limitations for certain diagnoses or methods of care delivery.
2. Review your internal digital medicine philosophy.
   • For example, if your workforce is often traveling or located in areas with fewer providers, perhaps more coverage of digital medicine is a beneficial option.
3. For self-insured plans: ensure alignment between your digital medicine philosophy and your vendor’s coverage.
4. Market coverage options to your employees.

To gain alignment and improve transparency with your digital medicine coverage, the first steps are to evaluate your employees’ need, and conduct a thorough investigation into your plans’ coverage options. Next, work with your vendor to adjust coverage to incentivize high valued care based on your employee population. Finally, communicate any changes and coverage updates to your employees.

As a vendor management firm focused exclusively on HR programs, vendors, and systems, Optimatum supports your efforts to ensure appropriate digital medicine coverage through an in-depth analysis of your workforce, vendor realignment for ideal digital coverage, and ongoing monitoring to ensure compliance.

Please contact us for more information on how we can work together to optimize your coverage.

Optimatum is a vendor management firm that focuses exclusively on the HR supply chain, including Employer Sponsored Healthcare, Retirement and HR Systems vendors. Our turnkey solutions improve the financial, operating performance, transparency and accountability of HR Benefit programs while still maintaining existing vendor relationships.

Our support of the HR workstream during the M&A lifecycle encompasses operational due diligence, day-one readiness and post day-one synergies. We assist sponsors in leveraging the aggregate purchasing power of their portfolio to capture value and drive margin expansion.

^{i. https://www.ama-assn.org/system/files/issue-brief-commercial-payer-coverage-digital-care.pdf
ii. Current Procedural Terminology codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval#:~:text=Code%20applications%20%26%20criteria-,What%20is%20a%20CPT%C2%AE%20code%3F,reporting%2C%20increase%20accuracy%20and%20efficiency}