Centers for Medicare and Medicaid Services Support for E-Consult Reimbursement

In December, the Association of American Medical Colleges (AAMC) and Virginia Medicaid (Department of Medical Assistance Services) met with the Centers for Medicare and Medicaid Services to discuss Medicaid’s payment policies with a focus on new concerns that have been raised in some states about the ability of Medicaid to provide a federal match for e-consult reimbursement.

Scott Shipman, MD, MPH, directs AAMC’s Project CORE (Coordinating Optimal Referral Experiences).  He and colleagues presented evidence of the impact of e-consults from the payer and patient perspectives, emphasizing the benefits especially to Medicaid beneficiaries given the difficulties they can have with access to timely specialty care. Questions from CMS included:

Q: How can e-consult support the delivery of mental/behavioral health?

A: Primary care providers can consult with mental and behavioral health providers to address needed care for patients, avoiding unnecessary patient travel, time off work, and additional costs to see a specialist.

Q: Does this service prevent patients from seeing a specialist?

A: No, e-consult is meant for routine, non-urgent patient needs. The primary care provider and patient always have the option to refer the patient for a face-to-face visit. Conversely, if the specialist feels the e-consult question is too complex or the patient needs to be seen, they can convert the e-consult to a referral for a face-to-face visit.

Q: Is cost-sharing required of patients?

A: Yes, in the Medicare FFS program, when billing requirements are met, beneficiaries are responsible for coinsurance for each CPT code (99451, 99452). Commercial payers, Medicare Advantage, and Medicaid plans have greater flexibility to address cost-sharing in their programs.

Q: What does the CMMI pilot entail?

A: The AAMC Project CORE program was launched in 2014 through a CMMI Health Care Innovation Award in partnership with UCSF and five academic medical centers. The pilot demonstrated improved access to specialty care, decreased costs, and high patient and provider satisfaction. Based on the results of the pilot and growing interest in e-consults, Project CORE has since been scaled to over 40 health systems and children’s hospitals enabling timelier access to specialty care for primary care patients across the country. 

CMS shared that they are committed to Medicaid payment policies that ensure equitable access to care and are actively reviewing e-consults.  They were particularly interested in the role of eConsults in service of mental and behavioral health needs.

The impact of AAMC’s targeted advocacy efforts emerged in President Biden’s recent State of the Union fact sheet on mental health, where the Administration states its commitment to support for integrating mental health and substance use treatment into primary care settings, including “payment models that support the delivery of whole-person care through behavioral health integration and authorize Medicaid reimbursement of inter-professional consultations so that primary care providers can consult with a specialist and provide needed care for patients.”

AAMC Project CORE continues to actively advocate for optimal e-consult payment policies to promote further scale and sustainability of this clinical innovation. The E-Consult Workgroup will continue to share the important advocacy efforts of AAMC and others. Questions can be shared with Meaghan Quinn, Program Lead, AAMC (