Even if you're not directly interested in "Digital Medicine," it's of interest when someone demonstrates wide and unexplained variance in the coverage of an area of services and coding.
AMA, with Manatt, looked at payer coverage of four code categories (such as digital remote monitoring) that are now represented by CPT codes. Coverage at 16 health plans was assessed (not surprisingly, about a dozen are variants of Blues plans). Take home lesson: Coverage varies widely.
Find the 19 page PDF report here. See a sample in the pic below.
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| Sample |
The report's take home lessons...
1. There is a lack of alignment across commercial, Medicare and Medicaid plans regarding coverage of digital medicine CPT codes. This lack of alignment makes it difficult for physicians to reliably provide digital services and for the consumer to know what services are accessible to them.
2. Within the commercial market, there is inconsistent adoption of new digital medicine CPT codes.
3. The level of transparency regarding coverage of digital medicine services is highly variable across
commercial health plans.
4. There are varying processes and timelines for adopting new CPT codes across health plans.
5. There is limited widespread utilization of most new digital health CPT codes, and health plans are eager for research on the impact and quality of digital medicine services.
6. Health plans often partner with health tech companies directly to provide digital health services to
members, but these directly-contracted services are often disconnected from a patient’s medical home.
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Not out yet, but look for a peer reviewed article in the coming months about PGx variability at payers, I heard it mentioned at a conference. Same issue - high payer variability.
