Telehealth vs. Telemedicine: What is Covered by Insurance
During (and even before) the COVID-19 pandemic began, virtual care options gained popularity with both patients and healthcare providers. New terms like Telehealth and Telemedicine were coined – and soon this type of care became a widely accepted form of healthcare.
However, the terms that describe virtual care have caused some confusion among patients and their care givers. Telehealth and Telemedicine sound similar and look like they could mean the same thing, but they are entirely different.
The Telehealth vs. Telemedicine Dilemma
The main cause of confusion for patients is that “telehealth” and “telemedicine” are commonly used interchangeably to describe general virtual care. While similar in sound, they are completely different when it comes to what is fully covered by insurance and what is not.
To help clear up the telehealth vs. telemedicine dilemma, we have outlined the definitions of the two terms and provided examples on how they apply to patient’s financial responsibility.
What is Telehealth?
Telehealth is a general term used to describe clinical services provided to patients through electronic communications (like Zoom or Microsoft Teams) that are not through a vendor like Teledoc or Doctor on Demand.
A good rule of thumb is – if you are consulting with a designated doctor or specialist office and not a Telemedicine vendor, you will be required to cover the expenses related to the consultation as if it were in-person.
Here is an example:
A man named Richard has a sore throat and his neck feels swollen. He is concerned about strep throat and wants to schedule a visit with his Primary Care Provider, who he has been going to for many years.
The day before his appointment, a massive snowstorm hits his town. Instead of digging out his car while sick, Richard calls his doctor’s office and asks if the consultation can be done virtually.
His doctor agrees, and they meet at their regularly scheduled time through a video calling platform. Richard’s doctor diagnoses him with strep and writes him a prescription for antibiotics.
At the end of the virtual care visit, Richard receives an email from the office’s administrator with an attached bill for his consultation. This is no surprise bill, it’s his plan’s standard $25 co-pay – the same as it would have been for an in-office visit.
In this example, Richard’s consultation still counts as a “visit,” even though it was not on site – and will cost the same amount it would have if the consultation were to be in person.
This type of visit would fall under the category of Telehealth. Now, let’s define Telemedicine.
What is Telemedicine?
Telemedicine refers to care provided by a vendor that only provides clinical services virtually, solely through virtual communications means.
We will use Richard as an example again. In this scenario, Richard’s PCP has an influx of patients and can’t get an appointment on the books for him until the following week.
With the snowstorm approaching and his symptoms escalating, Richard decides to utilize a Telemedicine vendor and schedules a consultation appointment for the following day.
The doctor at the Telemedicine vendor reviews Richard’s symptoms, looks at his throat, and diagnoses him. She sends him a valid prescription that will clear up his strep within a week.
Richard expected to receive a bill, but he remembered that his insurance plan covers all Telemedicine vendor consultations. This coverage was outlined when we received his Statement of Benefits from the vendor.
The Difference Between Telehealth and Telemedicine
At the end of the day, Telehealth and Telemedicine both describe types of virtual care provided by a licensed healthcare provider. However, the difference comes down to what is covered by insurance and what a patient is responsible for financially.
To sum it up, if you are scheduling a virtual care visit with a doctor or specialist (including your Primary Care Provider or Urgent Care) that is not connected to a specific Telemedicine provider, the care you will receive is considered Telehealth.
If you are working directly with a designed virtual care provider that is separate from a doctor or specialist office, the care you will receive is considered Telemedicine – and is usually covered fully by most insurance carriers.