Charging for portal use: Here is what urologists should know

Established patients with chronic problems may push back against charges.

Robert A. Dowling, MD, president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care

Robert A. Dowling, MD, writes, "How you communicate with patients is critical to satisfaction, outcomes, efficiency, and your practice’s success."

Cleveland Clinic recently announced that it will begin billing patients or their insurance company for responses to portal messages that require provider “clinical time and expertise.”1 Providing patients electronic access to their health information is one of the Merit-based Incentive Payment System (MIPS) measures in the Promoting Interoperability category, and it carries the largest weight in the category score premised on the belief that electronic exchange of data between a provider and a patient is important and improves health outcomes.2 That access typically involves a portal with many features, including the ability to exchange secure messages with providers or the care team. Providers have expressed concern that patients will overwhelm them with messages that consume uncompensated time. In this article, I will explore the trends that led to this point and the pros and cons of using portals from the physician and patient perspectives—all to inform your decision about whether to charge for responding to messages.

Trend 1: Changes in how we communicate. Americans are increasingly adopting asynchronous electronic methods for personal and business communications. More than 90% of adults use email regularly, most have a smartphone and use text messaging, and social media use is pervasive. The remote worker economy has only accelerated this trend. Almost half of young adults report they are “almost constantly online,”3 and a great deal of that involves posting, chatting, and other asynchronous communications. Live chat functionality is a routine feature of the internet presence of banks, retailers, and even some hospitals. In short, we have come to expect a standard of sending a message and getting a reply—usually for free—in all areas of our lives.

Trend 2: Changes in how physicians get paid. For 30 years, physicians have been paid on the principle that payments should be related to the resource costs needed to provide services—the resource-based relative value scale (RBRVS)—based on physician work, practice expenses, and malpractice expenses.4 Shortly after the introduction of RBRVS came the concept of evaluation and management (E&M) codes based upon the type and severity of patient conditions and, occasionally, the amount of time spent with the patient. Two recent developments have increased the expectation by physicians that they should be compensated primarily for time: the expansion of telehealth and reimbursement for phone calls, and the recent (2021) change in E&M coding guidelines to make it easier to base charges on the amount of time spent with the patient.

Trend 3: Changes in traditional physician “workload.” Reimbursement pressures and practice expense inflation have driven many physician practices to respond by seeing more patients per unit of time. The physical workload contributes to a mental workload that is demonstrably linked to physician burnout and has been exacerbated by the COVID-19 pandemic.5 The expanded office visit template may come at the expense of a contracted amount of time for non–face-to-face activities—responding to messages, for example.

Trend 4: Incentives for portal adoption. Most physicians in America have adopted an electronic health record (EHR), claimed up to $44,000 in incentives for doing so, and are compensated for Medicare professional services based in part on their continued adoption of features like providing patients access to information in the EHR through a portal. In 2020, it is estimated that 60% of patients nationwide were offered access to a portal, 60% of those accessed it at least once, and the most frequent activity reported (60%) was exchanging secure messages with their provider (up from 48% in 2017)6; review of 2020 MIPS data suggests higher rates of portal adoption in urology practices than in other specialties.7

Trend 5: Expansion of telehealth during the COVID-19 pandemic. This trend has increased the expectation that many services previously only offered in an office setting are available remotely via technology.

Taken together, these trends suggest an increased demand by patients for messaging their providers, a decreased supply of uncompensated physician time in which to do so, and a natural response to charge for messaging. It is important to draw a distinction between a brief round of secure messaging and something closer to a clinical encounter. Medicare has paid for the latter—“e-visits”—since 2019. An e-visit applies only to established patients and is described by Medicare as a patient-initiated online digital E&M service conducted via a patient portal.8 There are 3 levels of codes for up to 7 days’ cumulative time: 5 to 10 minutes, 11 to 20 minutes, and 21 or more minutes. The 2022 Medicare allowables for e-visit levels (unadjusted for geographic factors) are $15.23, $29.76, and $48.45, respectively. Medicare deductibles and coinsurance apply, and private insurance may have different rules.

Portals are attractive to patients as an alternative (to a phone message) channel for communicating a clinical concern. They can avoid call centers, “telephone tag,” and create a written record of their interaction. Patients can communicate from their phone or computer at a time they choose. Many physicians prefer this channel for the same reasons. Some literature suggests portal use is associated with higher patient satisfaction.9 Literature on provider satisfaction is lacking, and it is not clear whether portals improve or worsen productivity and efficiency or lead to decreased phone messages.10

Here’s how Cleveland Clinic is implementing billing for responding to messages1:

  • Giving advance notice
  • Proactively reaching out to patients with an easy-to-understand description of the new policy
  • Charging for the following if they are expected to take more than 5 minutes of provider time: changes to medications, new symptoms, changes to a long-term condition, and requests to complete medical forms
  • Not charging for: scheduling an appointment or asking a question that leads to an appointment, refilling prescriptions, following up on care within the past 7 days, and giving a quick update to the provider

Here are some additional things to think about before you charge for e visits:

  1. Asynchronous messaging may be less efficient than a phone call when evaluating a new clinical problem. Patients may omit critical information in their initial outreach or be vague, leading to several rounds of back-and-forth.
  2. Many EHRs do not have an automatic way of creating an encounter or charging from the messaging platform. You will have to create a workflow to initiate the charge/claim. Reimbursement for an e-visit is based on cumulative time over 7 days. You will have to establish a method of accounting for and documenting time in a 7-day “episode.”
  3. Charges will generate revenue cycle management. A sudden surge of claims for e-visits may trigger an inquiry from payers. You may need documentation to show which portal messages generated charges and which did not.
  4. A financial transaction may raise patient expectations about the quality and timeliness of your response to their message, especially if costs are largely out of pocket. There are no coding guidelines for documentation of an e-visit beyond the time parameters mentioned above.
  5. Medicare’s definition of an e-visit explicitly communication with a practitioner. You cannot bill for responses from your nurse or medical assistant.
  6. Established patients with chronic problems may push back on change. An example would be a female patient with chronic urinary tract infections who is accustomed to calling for an antibiotic periodically with new onset of symptoms. Depending on your market and your competitors’ policies, patients may leave.
  7. Charging for clinical responses may discourage patients from reporting new symptoms or using the portal to view their health information.

The bottom line and why it matters

How you communicate with patients is critical to satisfaction, outcomes, efficiency, and your practice’s success. The consumer economy demands electronic access to health care information, and portal adoption has surged in recent years. The decision whether to routinely charge for online “care” is therefore important and should be made in the context of your practice culture and style. If you decide to charge for responses to portal messages, be sure to make your policy clear on the portal before those messages are initiated by patients.

References

1. MyChart messaging. Cleveland Clinic. Accessed December 9, 2022. https://bit.ly/3Pcvott

2. 2018 Physician Fee Schedule final rule—Quality Payment Program final rule. Fed Regist. 2018;83(226):59789. To be codified at 83 FR 359186. https://bit.ly/3YcXKrk

3. Faverio M. Share of those 65 and older who are tech users has grown in the past decade. Pew Research Center. January 13, 2022. Accessed December 9, 2022. https://bit.ly/3FC40BU

4. McCormack LA, Burge RT. Diffusion of Medicare’s RBRVS and related physician payment policies. Health Care Financ Rev. 1994 Winter;16(2):159-173.

5. Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022;97(12):2248-2258. doi:10.1016/j.mayocp.2022.09.002

6. Johnson C, Richwine C, Patel V. Individuals’ access and use of patient portals and smartphone health apps, 2020. Office of the National Coordinator for Health Information Technology. September 2021. Accessed December 9, 2022. https://bit.ly/3iMkhLA

7. Doctors and clinicians datasets. Centers for Medicare & Medicaid Services. Accessed December 9, 2022. https://bit.ly/3CZ9vqY

8. Medicare telemedicine health care provider fact sheet. Centers for Medicare & Medicaid Services. March 17, 2020. Accessed December 9, 2022. https://bit.ly/3W7HmXE

9. Kinney AP, Sankaranarayanan B. Effects of patient portal use on patient satisfaction: survey and partial least squares analysis. J Med Internet Res. 2021;23(8):e19820. doi:10.2196/19820

10. Carini E, Villani L, Pezzullo AM, et al. The impact of digital patient portals on health outcomes, system efficiency, and patient attitudes: updated systematic literature review. J Med Internet Res. 2021;23(9):e26189. doi:10.2196/26189

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