Let's Talk Telehealth

Everyday investors net +$60M in proceeds from the sale of exclusive assets

From CEOs to shop owners, investors in Masterworks’ art offerings have received more than +$60,000,000 in total net proceeds to date (including principal) across their 23 exits.*

Surprised that so many people are interested in art investing? Bank of America recently found 83% of wealthy American investors 43 and under already collect, or want to. Normally, only the top 1% of investors would be able to diversify with art like Picassos and Banksys. But with Masterworks, you can easily diversify into this asset class without needing millions, or art expertise.

With a team that’s been working since 2019, Masterworks investors have realized representative annualized net returns like +17.6%, +17.8%, and +21.5% (among assets held for longer than one year).

Our readers can even SKIP THE WAITLIST.

Past performance not indicative of future returns. Investing Involves Risk. See Important Disclosures at masterworks.com/cd.

We all have so much to get done for year end—maybe not quite as much as Congress does, though! 🫢 

I’m paying close attention to the December 20th deadline to fund the government, which should be some combination of a Continuing Resolution (CR) through perhaps the first quarter of 2025 and for healthcare, addressing some expiring “healthcare extenders.”

That includes telehealth (especially waiving originating site requirements), the hospital-at-home waiver, a “conversion factor fix” to the physician fee schedule, an extension of the Advanced Alternative Payment Model (AAPM) bonus for Qualifying APM Participants (QPs), to name a few.

I get a lot of questions about telehealth.

And for good reason. Between insurance coverage, provider types, audio-only, risk-adjustment, originating site requirements, ACO implications, it is a lot to keep track of and keep straight!

So today, I’ll share answers to a few frequently asked questions. Here we go!

Will we still be able to provide telehealth on January 1st?

It depends. I hate that answer, so unsatisfying, right?

Most insurers pay for telehealth. But it’s not so straightforward in Medicare.

Let’s actually start with Medicare Advantage.

Telehealth was added as a basic benefit option that Medicare Advantage plans can add to their plans. It was finalized during the first Trump Administration. So any services approved by CMS in either the provisional or permanent list can be delivered by the providers permitted in CMS regulations without concern for the “geographic and site origination requirements,” which are still in place in Medicare Fee-For-Service (but waived through December 31, 2024 as part of the Consolidated Appropriations Act of 2023).

This Kaiser Family Foundation’s brief explains the “originating site requirements” well as they describe the temporary Congressional extension of waiving them:

Medicare Advantage plans and providers caring for patients with MA can track presently covered services as they are updated every year, and track other changes like Congressional updates to the Code

MA plans may also offer some additional benefits through their supplemental package of benefits that are not covered by Traditional Medicare.

Why can’t telehealth just be allowed in Medicare FFS? 

Because it’s not codified in statute and no funds are appropriated by Congress.

In Medicare Advantage, there are wide flexibilities built into statute for CMS to manage through rulemaking.

The key is that CMS can make changes to MA liberally, but CMS doesn’t add more funding. CMS can move funding around some through rulemaking, but they can’t add dollars available. Only Congress can do that.

In other words, if a plan wants to take advantage of flexibilities allowed through CMS, they are responsible for the utilization and spending incurred by offering them. Plans have to take into account telehealth spending, like all anticipated spending, as they make their bids to CMS for the upcoming year.

Is adding telehealth services permanently expensive?

In FFS, there is a big appropriations number attached to adding telehealth permanently through Congress to the tune of multiple billions per year. So until Congress can find a legislative package where they can add this permanently and fund it, temporarily-expanded telehealth benefits will have to be funded through sources like the Medicare Improvement Fund.

This tees up an opportunity to tie-in value-based care. I didn’t plan that, I swear!

It’s not just MA that has expanded telehealth benefits in Medicare. The Balanced Budget Act of 2018 also permits certain Accountable Care Organizations to apply for the “telehealth waiver.” ACOs that use “prospective alignment” (the minority of MSSP ACOs but the only option in ACO REACH entities) and who take downside risk, not just shared savings through participation in MSSP Tracks A and B, are able to apply for the telehealth waiver.

Why ACOs? How is that similar to MA?

Because the ACO is responsible for beating their financial benchmark. They are incentivized to stay within a given budget. They do that my reducing avoidable and unnecessary medical spending and providing more coordinated, person-centered, team-based care, among other things.

ACOs with downside risk owe CMS for spending above their benchmark (after the Minimum Loss Rate (MLR) threshold in MSSP).

So the thinking is that if an ACO applies for and offers telehealth, they are responsible if it only increases spending but doesn’t impact downstream spend prevention and causes the ACO to owe money to CMS.

Because…. 🥁🥁 🥁 …

Medicare Fee-for-Service is a spending free-for-all. There are no protections for the Federal Budget if spending is higher than predicted, if the right care isn’t provided at the right time, if patients don’t learn to manage chronic conditions well, if patients can’t manage their medications (or afford them)…you get the picture.

There’s no meaningful way to prevent abuse/overuse in Medicare FFS, so Congress has to be cautious about what additional services they agree to include and pay for. So part of what Congress is looking at while they temporarily extend flexibilities and appropriate dollars based on Congressional Budget Office estimates is the impact of the expansion of telehealth on spending in the Physician Fee Schedule.

Not that cause and effect are so easy to correlate, but I digress…

Here’s more on Medicare FFS and telehealth:

If Congress doesn’t extend the telehealth flexibilities and appropriations, anyone billing for telehealth for FFS beneficiaries based on those flexibilities will need to stop doing so on December 31, 2024, except in the case of many behavioral health services and a few other permanent services.

What’s the deal with audio-only telehealth services?

Audio-only telehealth has been available for a limited number of codes in the last few years. For 2025, that permanent list is expanded. Two things to note:

1. Audio-only visits may be offered if the patient can’t meet the requirement for audio-visual telehealth and code qualifies. A provider can’t schedule audio-only visits unless it’s patient-driven. Providers must always be able to provide audio-visual telehealth services through a compliant platform, and schedule audio-only if requested by the patient.

2. Audio-only visits do no meet the statutory requirement for ICD-10s captured on the visit to count towards CMS-HCC risk adjustment. So if you are a provider taking risk and prioritizing complete and accurate condition-capture, the diagnoses made on audio-only visits can’t contribute to risk adjustment. Modifier 93 is added to the claim to note that the visit was audio-only.

I’m a physical therapist. Am I permanently allowed to provide telehealth services for Medicare beneficiaries?

No, that hasn’t changed. CMS doesn’t have the statutory authority to add PTs, OTs, STs to the telehealth providers list. They also haven’t added therapy codes to the permanent telehealth list. The ones on the list remain provisional.

If Congress doesn’t act by by the end of 2024, rehab therapists will no longer be able to provide telehealth for Medicare FFS beneficiaries.

So the bottom line is it’s unlikely Congress will let telehealth flexibilities expire. It would be very unpopular. While another extension is likely, the timing of permanently legislating on the extended telehealth flexibilities is hard to predict. ⏲️ 💲