Research · 6 min read
What One State Requires Before an Audio-Only Visit May Be Billed
Washington's telemedicine reimbursement statute treats a phone call differently from a video call, defines the prior relationship it demands in dates and appointment types, and requires consent to the billing before the service happens.
Key takeaways
- RCW 48.43.735 is a Washington insurance reimbursement statute, not a general rule about when a clinician may practice by phone.
- Washington defines audio-only telemedicine as real-time audio communication for diagnosis, consultation or treatment, and excludes facsimile, email, and calls customarily not billed as separate services such as sharing laboratory results.
- For audio-only services the statute adds an established-relationship condition: access to sufficient health records, plus either a prior in-person or real-time audio-and-video appointment within the past three years, or a referral from a provider who had one.
- A provider intending to bill a patient or plan for an audio-only service must obtain consent for the billing in advance of the service being delivered.
- Washington's disciplinary statute, RCW 18.130.180, lists a pattern of violations of that billing-consent subsection among the grounds constituting unprofessional conduct.
- The statute expressly preserves plan terms, including utilization review, prior authorization, deductible, copayment and coinsurance, and does not require reimbursement of a non-covered benefit or a non-contracted provider.
Answer first: this is a payment rule with a consent duty bolted on
RCW 48.43.735 is not a licensing statute. It sits in Washington's insurance code and it tells a health carrier when it must reimburse a provider for a service delivered remotely. Reading it as a rule about when a clinician may practice by phone would be reading it for something it does not say.
What it does say is unusually specific about the phone. The statute defines audio-only telemedicine as the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of the section, audio-only telemedicine does not include the use of facsimile or email, and it does not include the delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, such as the sharing of laboratory results.
That second exclusion is the one people miss. A call to read back a lab result is not what the statute is regulating. The statute is regulating a phone encounter billed as a service.
Washington's definition of telemedicine in the same section covers delivery through interactive audio and video technology permitting real-time communication, and states that for purposes of the section telemedicine includes audio-only telemedicine but does not include facsimile or email. So the statute treats a video visit and a phone visit as members of the same family, and then imposes an extra condition on the phone member alone.
The extra condition: an established relationship, defined in dates
The reimbursement conditions in RCW 48.43.735 apply to any covered service delivered by telemedicine or store and forward technology: the plan covers the service in person, the service is medically necessary, the service is recognized as an essential health benefit under the referenced federal provision as in effect on the stated date, and the service is determined to be safely and effectively provided through the technology according to generally accepted health care practices and standards, with the technology meeting state and federal privacy and security requirements.
One further condition applies only to the phone. The statute provides that beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
Established relationship is then defined, and the definition has two parts joined by an and rather than an or. The provider providing audio-only telemedicine must have access to sufficient health records to ensure safe, effective, and appropriate care services. And one of two histories must exist.
The first history: the covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing the audio-only service, or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under the cited chapters.
The second history: the covered person was referred to the audio-only provider by another provider who has had, within the past three years, at least one in-person appointment or one real-time audio-and-video appointment with the covered person, and who has provided relevant medical information to the audio-only provider.
Two features of that definition are worth naming. Three years is a fixed window, not a rule of thumb. And a prior video appointment counts — the relationship does not have to have begun in a room, so long as it was real-time with both audio and video.
Consent to the billing, obtained before the service
RCW 48.43.735 contains a duty that runs to the provider rather than the carrier, and it is about money rather than care.
If a provider intends to bill a patient or the patient's health plan for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered. In advance of the service being delivered is the operative phrase. Consent collected afterward, or collected as part of a statement rendered later, does not satisfy the sentence as written.
The statute then builds an enforcement path that runs through the insurance regulator and lands at the licensing board. If the commissioner has cause to believe that a provider has engaged in a pattern of unresolved violations of that subsection, the commissioner may submit information to the appropriate disciplining authority for action. Before doing so, the commissioner may provide the provider with an opportunity to cure the alleged violations or to explain why the actions in question did not violate the subsection.
If the provider has engaged in a pattern of unresolved violations, the appropriate disciplining authority may levy a fine or cost recovery upon the provider in an amount not to exceed the applicable statutory amount per violation, and take other action permitted under its authority. On completing its review, the disciplining authority must notify the commissioner of the results, including whether the violation was substantiated and any enforcement action taken.
Washington closed the loop in its licensing chapter. RCW 18.130.180 lists the conduct that constitutes unprofessional conduct for a license holder under that chapter, and one of the enumerated items is a pattern of violations of a set of cited provisions that includes RCW 48.43.735(8). A billing-consent failure is therefore not only an insurance matter in Washington; a pattern of them is written into the state's disciplinary grounds.
Where the patient may be, and who may charge a facility fee
The statute lists the originating sites for a telemedicine service subject to its reimbursement requirement, and the list is broader than a clinic.
It includes a hospital, a rural health clinic, a federally qualified health center, a physician's or other health care provider's office, a licensed or certified behavioral health agency, a skilled nursing facility, a renal dialysis center other than an independent one, and — the item that matters for a consumer-facing service — home or any location determined by the individual receiving the service.
Washington also states that a health carrier may not distinguish between originating sites that are rural and urban in providing the required coverage. Geography does not change the obligation.
The facility fee rules are drawn narrowly. Any originating site other than the home-or-any-location category may charge a facility fee for infrastructure and preparation of the patient, subject to a negotiated agreement with the carrier. A distant site, a hospital that is an originating site for audio-only telemedicine, and any other site not identified in the list may not charge a facility fee. The distant site is where the provider is; the statute is explicit that the provider's own location cannot generate a facility charge.
What the statute leaves to the plan, and what it does not require at all
It would be a misreading to treat RCW 48.43.735 as a guarantee that a remote visit is covered and free of the plan's usual machinery. The statute says the opposite in plain terms.
A health carrier may subject coverage of a telemedicine or store and forward service to all terms and conditions of the plan in which the covered person is enrolled, including but not limited to utilization review, prior authorization, deductible, copayment, or coinsurance requirements that apply to a comparable service provided in person.
The section also states three things it does not require a carrier to reimburse: an originating site for professional fees, a provider for a health care service that is not a covered benefit under the plan, and an originating site or health care provider when the site or provider is not a contracted provider under the plan. A remote visit with a clinician outside the network is not converted into a covered service by this statute.
On payment amount, the statute requires a carrier to reimburse a provider for a service provided through telemedicine the same amount of compensation the carrier would pay if the service were provided in person, and then names the parties permitted to negotiate away from that: hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate a different amount. For that purpose, the number of providers in a group refers to all providers within the group, regardless of a provider's location.
Store and forward technology is treated differently again. Reimbursement of store and forward technology is available only for those covered services specified in the negotiated agreement between the carrier and the provider, and the statute's definition of store and forward technology excludes audio-only telephone, facsimile, and email.
All of this is Washington's answer, written for Washington carriers and the providers who bill them. It describes no other state, and a program operating in several states may be following several different sets of conditions at once.
Sources
- Revised Code of Washington 48.43.735 — Reimbursement of health care services provided through telemedicine or store and forward technology — Audio-only telemedicineThe reimbursement conditions for telemedicine and store and forward technology; the audio-only established-relationship condition and its stated start date; the full definition of established relationship including the three-year window and the alternative referral route; the definitions of audio-only telemedicine, telemedicine and store and forward technology and their exclusions; the requirement to obtain patient consent for billing in advance of an audio-only service; the commissioner's referral path, the opportunity to cure, and the disciplining authority's fine or cost recovery and notification duty; the originating site list including home or any location determined by the individual; the prohibition on distinguishing rural and urban originating sites; the facility fee rules including the prohibition on a distant site charging one; the payment parity requirement and the categories permitted to negotiate a different amount, including provider groups of eleven or more counted regardless of location; the preservation of plan terms including utilization review, prior authorization, deductible, copayment and coinsurance; and the three categories the section does not require a carrier to reimburse.
- Revised Code of Washington 18.130.180 — Unprofessional conductThe enumerated ground of unprofessional conduct consisting of a pattern of violations of a set of cited provisions that includes RCW 48.43.735(8), which is the audio-only billing-consent subsection.
Frequently asked questions
Does Washington require a prior relationship before a phone visit?
For reimbursement purposes under RCW 48.43.735, yes. The statute conditions a carrier's obligation to reimburse an audio-only telemedicine service on the covered person having an established relationship with the provider, beginning January 1, 2023. That is a condition on payment written into an insurance statute; it is not a general licensing prohibition, and it describes only Washington.
What counts as an established relationship?
RCW 48.43.735 requires both that the provider has access to sufficient health records to ensure safe, effective, and appropriate care services, and that one of two histories exists. Either the covered person has had, within the past three years, at least one in-person appointment or one real-time interactive appointment using both audio and video technology with that provider or a provider at the same medical group, clinic, or carrier-operated integrated delivery system. Or the covered person was referred by another provider who has had such an appointment within the past three years and has provided relevant medical information.
Does a previous video visit count, or does it have to have been in person?
The definition names both. At least one real-time interactive appointment using both audio and video technology within the past three years satisfies the requirement, as does at least one in-person appointment in that window. What the definition does not accept in place of either is a prior audio-only contact.
What has to happen before a provider bills for a phone visit in Washington?
RCW 48.43.735 states that if a provider intends to bill a patient or the patient's health plan for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered. The statute then allows the insurance commissioner to refer a pattern of unresolved violations to the appropriate disciplining authority, which may levy a fine or cost recovery not to exceed the applicable statutory amount per violation.
Can a patient be at home for a covered telemedicine visit?
The originating site list in RCW 48.43.735 includes home or any location determined by the individual receiving the service, alongside hospitals, clinics, provider offices and several facility types. The statute also provides that a carrier may not distinguish between rural and urban originating sites in providing the required coverage, and that the home-or-any-location category may not charge a facility fee.
Does this statute mean a telehealth visit costs nothing out of pocket?
No. RCW 48.43.735 states that a carrier may subject coverage to all terms and conditions of the plan, including utilization review, prior authorization, deductible, copayment or coinsurance requirements applicable to a comparable in-person service. It also states that the section does not require a carrier to reimburse a provider for a service that is not a covered benefit, or a provider who is not contracted under the plan.