Health Plans Scramble To Publish New Policies On COVID-19 Testing, Diagnosis and Treatment

MORRISVILLE, NC—Policy Reporter, a Mercalis (formerly TrialCard)-owned medical policy tracking platform for physicians, health plans, laboratories, and product manufacturers, has over the past week alerted its clients to dozens of new and updated payer policies related to the COVID-19 virus. Many of these new policies include the elimination of patient cost-sharing expense for COVID-19 testing, in line with the Families First Coronavirus Response Act, which requires most health plans to cover testing at no cost to the plan member. Due to stay-at-home and self-quarantine mandates, many health plans are also adopting significant changes to their rules for covering telehealth services, including waiving patient cost-sharing expense and expanding access to these services.

“Policy Reporter is seeing more commercial health plans cover telehealth services at no cost to the plan member,” says Scott Dulitz, Chief Strategy Officer at Mercalis (formerly TrialCard). “Many smaller regional plans are following the lead of large national plans that have announced their intent to cover telehealth services in this manner. This includes all Blue Cross Blue Shield plans as well as Aetna, Anthem, and Humana. Combined, these plans represent more than 165 million covered lives. In addition, Aetna just announced that plan member costs for in-network hospital stays related to COVID-19 treatment will be waived through June 1 for at least 3.6 million of their members.”

The Centers for Medicare and Medicaid Services (CMS) has also updated its policies covering telehealth services, allowing Medicare patients to access an increased scope of benefits without certain coverage limitations that were previously imposed. This is placing pressure on private plans to update their policies to provide access at parity with Medicare. Medicare cost-sharing expense for these services remains unchanged.

It is also expected that commercial health plans may publish and update policies that address services designed to assist members who are self-isolating, such as home health services. The Preserving Patient Access to Home Infusion Act (H.R. 6218) was introduced in Congress on March 12, 2020, with the goal of expanding Medicare beneficiary access to certain homecare services. The timing of the introduction of this bill considered that many treatments addressed by the Act are furnished to beneficiaries with significant COVID-19 risk factors. New policies will likely address the scope of services covered in the home setting, as health authorities have stated that patients with mild disease and no risk factors can be managed at home.

In addition, more plans are publishing provider guidance on billing and coding for COVID-19-related procedures and diagnosis. The American Medical Association’s (AMA) new billing code for COVID-19 testing, CPT 87635, is being adopted by plans quickly, with BCBS Rhode Island, BCBS Kansas, and United Healthcare among the most recent payers to publish guidance, including maximum billing frequency. Not all plans, however, are adopting the code, creating challenges for providers that rely upon uniform coding standards. The new ICD-10-CM diagnosis code (U07.1: 2019- nCoV acute respiratory disease) is not effective until October 1, 2020; however, the National Center for Health Statistics (NCHS) has developed interim guidance for ICD-10-CM coding, including pneumonia due to COVID-19: J12.89 (other viral pneumonia) and B97.29 (other coronavirus) as the cause of diseases classified elsewhere.

“While payers are moving quickly to update and publish new policies for reporting COVID-19 testing, diagnosis, and treatment, this is leading to some confusion among healthcare providers who must stay abreast of new guidance,” says Drew Gutschmidt, President of Policy Reporter. “We are seeing some inconsistency in billing and coding guidelines as providers begin to see an influx of patients. Policy Reporter will continue to monitor and report new and updated policies in this dynamic and urgent environment.”

Policy Reporter offers its PolicyCore subscription service to track COVID-19 policies to help physicians, payers, laboratories, product manufacturers, and other healthcare companies track and understand this changing policy landscape. Contact Policy Reporter at info@policyreporter.com to learn more.

About Policy Reporter
Policy Reporter provides innovative healthcare software solutions to track payer policies in near real-time and enhances market access for the therapies patients need most. The company’s patented software-driven solutions include a suite of billing and reimbursement tools for providers and laboratories, market intelligence tools for payers, and a suite of market access solutions for pharmaceutical and medical device companies. Its clients include some of the world’s largest pharmaceutical and healthcare companies. For more information or to request free demo, please visit https://www.policyreporter.com.

About Mercalis (formerly TrialCard)
Mercalis (formerly TrialCard Incorporated) provides patient affordability, medication access and adherence, patient support, and clinical trial services on behalf of pharmaceutical manufacturers. Founded in 2000, TrialCard has connected over 30 million patients with nearly $12 billion in branded drug savings to date. The company is headquartered in Morrisville, North Carolina. For more information about Mercalis (formerly TrialCard), please visit www.mercalis.com.