HEALTH CARE

Telehealth and 

Remote Patient 

Monitoring Use in 

Medicare and 

Selected Federal 

Programs

Report to Congressional Committees

April 2017

GAO-17-365

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-365, a report to 

congressional committees

April 2017

HEALTH CARE

Telehealth and Remote Patient Monitoring Use in 

Medicare and Selected Federal Programs

What GAO Found

Selected associations representing providers and patients most often cited the 

potential to improve or maintain quality of care as a significant factor that 

encourages the use of telehealth (providing clinical care remotely by two-way 

video) and remote patient monitoring (monitoring of patients outside of 

conventional settings) in Medicare. For example, according to officials from a 

provider association, telehealth can improve patient outcomes by facilitating 

follow-up care, while remote patient monitoring is helpful for treating patients with 

chronic diseases. With regard to factors that create barriers, the selected 

associations most often cited concerns over payment and coverage restrictions. 

For example, officials from a provider association noted that Medicare telehealth 

coverage restrictions limit the geographic and practice settings in which 

beneficiaries may receive services. While not indicating how significant these 

factors are to Medicare, officials with a payer association told GAO that they 

considered these factors—also identified by the provider and patient 

associations—as either encouraging use or creating barriers to the use of 

telehealth and remote patient monitoring.

Significance of Improving or Maintaining Quality of Care as a Factor that Encourages the Use 

of Telehealth and Remote Patient Monitoring in Medicare

Medicare models, demonstrations, and a new payment program have the 

potential to expand the use of telehealth and remote patient monitoring. The 

Centers for Medicare & Medicaid Services, an agency within the Department of 

Health and Human Services (HHS), supports eight models and demonstrations 

in which certain Medicare telehealth requirements have been waived, such as

requirements for the locations and facility types where beneficiaries can receive 

telehealth services. For example, the waivers allow beneficiaries to access 

telehealth in urban areas, or from their homes. Additionally, the use of telehealth 

and remote patient monitoring in Medicare may change depending on how many 

clinicians use them as a way to achieve the goals of the new Merit-based 

Incentive Payment System, which—starting in 2017—will pay clinicians based on 

quality and resource use, among other things. Under this payment program, 

clinicians can use telehealth and, in some instances, remote patient monitoring, 

to help meet the payment program’s performance criteria. For example, 

clinicians could use telehealth to coordinate care or use remote patient 

monitoring to remotely gather information to determine a patient’s proper dose of 

medication.

View GAO-17-365. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or Yocomc@gao.gov.

Why GAO Did This Study

Telehealth and remote patient 

monitoring can provide alternatives to 

health care provided in person at a 

physician’s office, particularly for 

patients who cannot easily travel long 

distances for care. Medicare pays for 

some telehealth services that are 

subject to statutory and regulatory 

requirements, such as requiring the 

patient be present at an originating site 

like a rural health clinic. 

The Medicare Access and CHIP 

Reauthorization Act of 2015 includes a 

provision for GAO to study telehealth

and remote patient monitoring. Among 

other reporting objectives, this report

reviews (1) the factors that

associations identified as affecting the 

use of telehealth and remote patient 

monitoring in Medicare and (2) 

emerging payment and delivery 

models that could affect the potential 

use of telehealth and remote patient 

monitoring in Medicare.

GAO reviewed agency documents and 

regulations and interviewed agency 

officials. GAO also selected nine 

general and medical specialty 

associations with expertise and interest 

in telehealth or remote patient 

monitoring—six provider, two patient, 

and one payer association—based on 

a review of relevant documents and 

literature and through background 

interviews. GAO interviewed 

representatives from each of the 

associations and collected information 

from the provider and patient 

associations through a data collection 

instrument.

GAO provided a draft of this report to 

HHS. In response, HHS provided 

technical comments, which were 

incorporated as appropriate.
Page i GAO-17-365 Telehealth and Remote Patient Monitoring

Letter 1

Background 6

Available Data Show Low Proportions of Beneficiaries Accessing 

Telehealth; Limited Data Are Available on Remote Patient 

Monitoring 14

CMS Uses Routine Claims Review Processes for Telehealth 

Payments and Is Examining Some Questionable Claims 

Identified by MedPAC 18

Selected Associations Report Telehealth and Remote Patient 

Monitoring May Improve Care for Medicare Beneficiaries, but 

Cited Coverage and Payment Restrictions as Barriers 21

CMS Has Various Efforts Underway That Have the Potential to 

Expand the Use of Telehealth and Remote Patient Monitoring in 

Medicare 27

Agency and Third-Party Comments 34

Appendix I Use of Remote Patient Monitoring by Selected Private Payers 38

Appendix II Scope and Methodology for Identifying Factors Affecting the Use of 

Telehealth and Remote Patient Monitoring 41

Appendix III Medicare Telehealth Services Added and Denied by the Centers for 

Medicare & Medicaid Services, 2011-2016 45

Appendix IV Telehealth and Remote Patient Monitoring Reimbursement and Use in 

Selected State Medicaid Plans 51

Appendix V Selected Associations’ Rating of the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring 53

Appendix VI Medicare Valuation of Remote Patient Monitoring 58

Contents
Page ii GAO-17-365 Telehealth and Remote Patient Monitoring

Appendix VII Examples of Telehealth and Remote Patient Monitoring in Medicare 

Models and Demonstrations 64

Appendix VIII GAO Contact and Staff Acknowledgments 66

Tables

Table 1: Summary of Federal Agency Telehealth Services and 

Originating Sites 13

Table 2: Medicare Telehealth Requirements Waived for Selected 

Models and Demonstrations 30

Table 3: Telehealth Use by Selected Models and Demonstrations 

with Waivers of Certain Medicare Requirements 32

Table 4: Potential Factors that Encourage the Use or Are Barriers 

to the Use of Telehealth or Remote Patient Monitoring in 

Medicare Used in the Data Collection Instrument 41

Table 5: Telehealth Service Codes Added by the Centers for 

Medicare & Medicaid Services (CMS), Calendar Years 

2011 through 2016 46

Table 6: Telehealth Service Codes Denied by the Centers for 

Medicare & Medicaid Services (CMS), Calendar Years 

2011 through 2016 48

Table 7: Reimbursement and Use of Telehealth and Remote 

Patient Monitoring in Selected State Medicaid Programs 51

Table 8: Centers for Medicare & Medicaid Services’ Innovation 

Center Categories and Examples of Potential Telehealth 

and Remote Patient Monitoring Use in Models or 

Demonstrations 64

Figures

Figure 1: Example of Telehealth Use in Medicare 9

Figure 2: Significance of Certain Factors That Encourage the Use 

of Telehealth and Remote Patient Monitoring in 

Medicare, According to Selected Provider and Patient 

Associations 22

Figure 3: Significance of Certain Barriers to the Use of Telehealth 

and Remote Patient Monitoring in Medicare, According to 

Selected Provider and Patient Associations 25
Page iii GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 4: Significance of Factors That Encourage the Use of 

Telehealth in Medicare, According to Selected Provider 

and Patient Associations 54

Figure 5: Significance of Factors That Encourage the Use of 

Remote Patient Monitoring in Medicare, According to 

Selected Provider and Patient Associations 55

Figure 6: Significance of Barriers to the Use of Telehealth in 

Medicare, According to Selected Provider and Patient 

Associations 56

Figure 7: Significance of Barriers to the Use of Remote Patient 

Monitoring in Medicare, According to Selected Provider 

and Patient Associations 57

Abbreviations 

ACO accountable care organization

AMA American Medical Association

CCO coordinated care organization

CHIP state Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services

DOD Department of Defense

HHS Department of Health and Human Services 

MAC Medicare Administrative Contractor

MedPAC Medicare Payment Advisory Commission

RUC American Medical Association/Specialty Society 

Relative Value Scale Update Committee

VA Department of Veterans Affairs

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Page 1 GAO-17-365 Telehealth and Remote Patient Monitoring

441 G St. N.W.

Washington, DC 20548

April 14, 2017

Congressional Committees

For certain individuals, such as those who live in remote areas or cannot 

easily travel long distances, access to health care services can be 

challenging. Telehealth and remote patient monitoring can provide an 

alternative to health care provided in person at a physician’s office.1

Telehealth can be used to provide clinical care remotely by two-way video 

for services such as psychotherapy or the evaluation and management of 

conditions. Remote patient monitoring can be used to monitor patients 

with chronic conditions, such as those with congestive heart failure, 

hypertension, diabetes, and chronic obstructive pulmonary disease, and it 

can also be used as a diagnostic tool, such as for some heart conditions.2

Although the literature is mixed on the effectiveness of telehealth and 

remote patient monitoring, a 2016 review of studies by the Agency for 

Healthcare Research and Quality—an agency within the Department of 

Health and Human Services (HHS)—found that the most consistent 

benefit of telehealth and remote patient monitoring occurs when the 

technology is used for communication and counseling or to remotely 

monitor chronic conditions such as cardiovascular and respiratory 

disease, with improvements in outcomes such as mortality, quality of life, 

and reductions in hospital admissions.3

In recent years there have been efforts to increase the use of telehealth 

and remote patient monitoring in federal health care programs. A federal 

strategic plan prepared by the Office of the National Coordinator for 

Health Information Technology within HHS calls for an increased use of 

 1

For this report, we define telehealth as clinical services that are provided remotely via 

telecommunications technologies, while remote patient monitoring is a technology to 

enable monitoring of patients outside of conventional clinical settings, such as in the 

home. Federal agencies have various definitions for telehealth, and in this report we show 

how these definitions vary across programs.

2

See Ashlea Bennett Milburn et al., “The Value of Remote Monitoring Systems for 

Treatment of Chronic Disease,” IIE Transactions on Healthcare Systems Engineering, vol. 

4, no. 2 (2014); David P. Kao et al., “Impact of a Telehealth and Care Management 

Program on All-Cause Mortality and Healthcare Utilization in Patients with Heart Failure,” 

Telemedicine and e-Health, vol. 22, no. 1 (2016).

3

Department of Health and Human Services, Agency for Healthcare Research and 

Quality, Telehealth: Mapping the Evidence for Patient Outcomes from Systematic 

Reviews, Technical Brief Number 26 (Washington, D.C.: June 2016).

Letter
Page 2 GAO-17-365 Telehealth and Remote Patient Monitoring

telehealth and remote patient monitoring in federal health care programs.4

Additionally, in the 21st Century Cures Act, enacted in December 2016, 

Congress expressed an interest in expanding the use of telehealth in 

Medicare through increasing the types of sites where telehealth can 

occur.5

While Medicare currently uses telehealth primarily in rural areas or 

regions designated as having a shortage of health professionals, in the 

future emerging payment and delivery models may change the extent to 

which telehealth and remote patient monitoring are available and used by 

Medicare beneficiaries and providers in other areas.6 The Centers for 

Medicare & Medicaid Services (CMS), another HHS agency, oversees 

Medicare payments for telehealth services. According to the 

Congressional Budget Office, the financial impact of expanding telehealth 

and remote patient monitoring in Medicare is difficult to predict—it may 

reduce federal spending if used in place of face-to-face visits, but it may 

increase federal spending if used in addition to these visits. Beyond the 

Medicare program, other federal programs, along with some private 

insurers, also pay for—or provide—some telehealth and remote patient 

monitoring services.7

The Medicare Access and CHIP Reauthorization Act of 2015 included a 

provision that we study telehealth and remote patient monitoring.8 In this 

report we

1. describe the extent to which telehealth and remote patient monitoring 

are used by Medicare and other federal programs to provide health 

care services;

2. assess the extent to which CMS oversees telehealth payments in 

Medicare;

 4

See Department of Health and Human Services, Office of the National Coordinator for 

Health Information Technology, Federal Health IT Strategic Plan 2015-2020.

5

Pub. L. No. 114-255, § 4012, 130 Stat. 1033 (2016).

6

For the purposes of this report, we use the term “provider” to refer to physicians and nonphysician practitioners, such as physician assistants and nurse practitioners.

7

Based on a 2016 study, over half of states had some requirement for telehealth coverage 

in private insurance. Bob Herman, “Virtual Reality: More Insurers Are Embracing 

Telehealth,” Modern Healthcare, vol. 46, no. 8 (2016).

8

Pub. L. No. 114-10, § 106, 129 Stat. 87, 140-142 (2015).
Page 3 GAO-17-365 Telehealth and Remote Patient Monitoring

3. describe the factors associations representing providers and patients 

rated—and payers cited—as affecting the use of telehealth and 

remote patient monitoring in Medicare; and

4. describe how emerging payment and delivery models could affect the 

potential use of telehealth and remote patient monitoring in Medicare.

Our report also describes the use of remote patient monitoring by 

selected health plans in the private insurance market (see app. I).

To describe the extent to which telehealth and remote patient monitoring 

are used by Medicare and other federal programs, we reviewed available 

data, statutes, regulations, and other relevant documentation related to 

telehealth in Medicare, Medicaid, the Department of Defense (DOD), and 

the Department of Veterans Affairs (VA).9 We interviewed agency officials 

from CMS as well as officials from DOD and VA, because the latter two 

departments operate federal programs outside of HHS that provide 

telehealth to their beneficiaries. The work we performed for each program 

included the following:

• For Medicare, we reviewed a June 2016 Medicare Payment Advisory 

Commission (MedPAC) report which, among other things, includes an 

analysis of Medicare telehealth and remote patient monitoring claims 

for calendar year 2014.10

• For Medicaid, we selected a sample of six states—Connecticut, 

Illinois, Kansas, Mississippi, Montana, and Oregon—to include in our 

review. We selected states that varied in geography, physical size, 

percentage of rural population, and other factors related to coverage 

and reimbursement for health care services. In particular, we 

considered factors such as the extent to which the state’s Medicaid 

 9

Federal agencies have various definitions for telehealth. A May 2014 study from a federal 

working group found that across the 26 agencies that participated in the workgroup, there 

were multiple unique definitions using the terms “telehealth” and “telemedicine.” Some 

agencies’ definitions were broad, for example, defining only the overarching clinical

interaction, while others included detailed descriptions of the technology involved. The 

study concluded that with agencies serving different populations and operating under 

different missions, a uniform definition of telehealth was elusive, though the study also 

concluded that the definitions overlapped. See Charles R. Doarn et al., “Federal Efforts to 

Define and Advance Telehealth—A Work in Progress,” Telemedicine and e-Health, vol. 

20, no. 5 (2014).

10We relied on the MedPAC analysis because it analyzed the most recent Medicare data 

available at the time we conducted our work. See Medicare Payment Advisory 

Commission, Report to the Congress: Medicare and the Health Care Delivery System, 

(Washington, D.C.: June 15, 2016), 229-260.
Page 4 GAO-17-365 Telehealth and Remote Patient Monitoring

program uses different payment systems, whether the state’s 

Medicaid program reimburses for telehealth, the type of locations for 

providing the services that were allowed, and the type and number of 

eligible providers. We obtained information about telehealth and 

remote patient monitoring use for the most recent state fiscal year 

available from four of the six states that had the information and also 

interviewed state officials from all six states about the use of 

telehealth and remote patient monitoring in their state, including any 

restrictions on and reimbursement for these services.11 Our findings 

for these six states cannot be generalized to other states.

• For DOD, we obtained data on the use of telehealth for fiscal year 

2015, the most recent fiscal year available, and we interviewed 

officials about the use of telehealth and remote patient monitoring in 

DOD’s health care program.

• For VA, we reviewed documentation, interviewed officials, and 

received data on the use of telehealth and remote patient monitoring 

for fiscal year 2016, the most recent fiscal year available.

To assess the reliability of the program data we used, we interviewed 

MedPAC officials on how they collected and analyzed Medicare data for 

their report; we obtained information from DOD and VA on the controls 

used by the programs to ensure that the data were accurate and 

complete. Based on these steps we determined that these data were 

sufficiently reliable for our purposes.

To assess the extent to which CMS oversees telehealth payments in 

Medicare, we reviewed related agency documentation and interviewed 

knowledgeable officials about the procedures used to review claims for 

telehealth services. Additionally, we reviewed MedPAC’s report on 

Medicare telehealth claims for calendar year 2014 and interviewed 

MedPAC officials to understand the basis for their findings.12 We 

 11Connecticut, Illinois, and Mississippi provided us with information from 2015, and 

Montana also provided information for 2013 through 2015. The remaining two states—

Kansas and Oregon—did not provide us with information about such things as numbers of 

patients or expenditures for telehealth or remote patient monitoring.

12Medicare Payment Advisory Commission, Report to the Congress: Medicare and the 

Health Care Delivery System.
Page 5 GAO-17-365 Telehealth and Remote Patient Monitoring

assessed CMS’s oversight procedures and the agency’s response to 

MedPAC’s findings using federal standards for internal controls.13

To describe the factors associations representing providers and patients 

rated—and payers cited—as affecting the use of telehealth and remote 

patient monitoring in Medicare, we developed a data collection instrument 

for three groups of selected associations—six associations that represent 

providers, two associations that represent patients, and one association 

that represents payers. The associations representing providers and 

patients completed our data collection instrument; the payer association 

did not.

14 To identify these associations, we reviewed relevant documents 

and literature and conducted interviews to identify relevant general and 

specialty associations. In the data collection instrument, we requested 

that the associations rate the significance of potential factors that may 

encourage the use of telehealth and remote patient monitoring and 

potential factors that may create barriers to their use. We identified these 

factors based on background research and initial interviews with two 

groups with an interest in telehealth. In addition to having the provider 

and patient associations rate the factors and having the payer association 

identify them, we also reviewed relevant documentation and interviewed 

officials from each provider, patient, and payer association using a 

structured question set to obtain examples, from their perspective, of how 

these factors can encourage the use of telehealth and remote patient 

monitoring in Medicare or create barriers to their use. The perspectives 

we obtained using the data collection instrument, from our document 

reviews, and during our interviews with association officials provided 

insights regarding the officials’ views on factors that encourage the use of 

telehealth and remote patient monitoring and factors that are barriers to 

their use. These perspectives cannot be generalized. See appendix II for 

more information on our data collection instrument and on our scope and 

methodology for identifying relevant associations and the factors, 

including the significance of the factors as rated by the associations.

 13See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014); and Standards for Internal Control in the Federal 

Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). Internal control 

is a process effected by an entity’s oversight body, management, and other personnel that 

provides reasonable assurance that the objectives of an entity will be achieved.

14A representative of the payer association we spoke with told us that the association did 

not have sufficient time to survey its members and could not complete our data collection 

instrument without doing so. Therefore, we reported separately the payer association’s 

views on factors that encourage the use of, or are barriers to, telehealth and remote 

patient monitoring.
Page 6 GAO-17-365 Telehealth and Remote Patient Monitoring

To describe how emerging payment and delivery models could affect the 

potential use of telehealth and remote patient monitoring in Medicare, we 

reviewed CMS documents describing and evaluating the models 

developed by the Center for Medicare & Medicaid Innovation (Innovation 

Center) to support alternative approaches to health care payment and 

delivery.15 We also studied implementation plans created by participants 

in one of the models, which outlined how the participants planned to use 

telehealth. We also interviewed knowledgeable agency officials about 

how telehealth was used in the models and how the models might affect 

telehealth and remote patient monitoring use in Medicare in the future. 

Additionally, we examined documents and interviewed CMS officials 

regarding a new Medicare payment program that allows the use of 

telehealth—and to some extent remote patient monitoring—to help 

achieve some of the goals of the payment program.

We conducted this work from March 2016 to April 2017 in accordance 

with generally accepted government auditing standards. Those standards 

require that we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained 

provides a reasonable basis for our findings and conclusions based on 

our audit objectives.

The federal government uses telehealth and remote patient monitoring in 

various health care programs, including the following:

• Medicare, which provides health care coverage for people age 65 or 

older, certain individuals with disabilities, and individuals with endstage renal disease;

• Medicaid, a joint federal-state health care financing program for 

certain low-income and medically needy individuals;

• DOD, which provides services through its regionally structured health 

care program to active duty personnel and their dependents, 

 15In 2010, the Patient Protection and Affordable Care Act created the Innovation Center 

within CMS to test new approaches to health care delivery and payment—known as 

models, or in some cases as demonstrations—in order to reduce Medicare, Medicaid, and 

state Children’s Health Insurance Program expenditures while preserving or enhancing 

quality of care for beneficiaries of the programs. See Pub. L. No. 111-148, §§ 3021, 

10306, 124 Stat. 119, 389, 939 (codified at 42 U.S.C. § 1315a).

Background
Page 7 GAO-17-365 Telehealth and Remote Patient Monitoring

medically eligible Reserve and National Guard personnel and their 

dependents, and retirees and their dependents and survivors; and

• VA, which delivers medical services to veterans primarily through an 

integrated health care delivery system.

Other federal agencies—within and outside of HHS—also provide grants 

to promote the use of telehealth.16

Medicare began paying separately for certain telehealth services after the 

passage of the Balanced Budget Act of 1997.17 The statute requires that 

Medicare, which covers over 50 million beneficiaries, pay for certain 

telehealth services, including consultations, office visits, and office 

psychiatry services, that are furnished through a telecommunications 

system with audio and video equipment permitting two-way, real-time 

interactive communication between the patient and distant site provider.18

According to CMS officials, Medicare fee-for-service does not have an 

explicit definition of remote patient monitoring. Rather, Medicare pays 

separately for some services that are used to remotely monitor patients, 

as well as for other remote monitoring bundled with other services. For 

 16For example, within HHS, the Health Resources and Services Administration promotes 

the use of telehealth technologies for health care delivery, education, and health 

information services through grant programs. It does this to, among other things, improve 

health care services for medically underserved populations, support the establishment and 

operation of resource centers that help in implementing telehealth services, and support 

implementation of telehealth networks to deliver 24-hour emergency department 

consultation services. Additionally, the U.S. Department of Agriculture administers grants 

through the Distance Learning and Telemedicine and the Community Connect programs. 

The Distance Learning and Telemedicine program funds institutions to support advanced 

telecommunications in health care and education in rural communities and is designed 

specifically to assist rural communities that would otherwise be without access to learning 

and medical services over the Internet. The Community Connect program provides 

financial assistance to state and local governments, federally-recognized tribes, non-profit 

organizations, and for-profit corporations in rural areas that lack a minimum broadband 

speed connection. 

17Pub. L. No. 105-33, § 4206, 111 Stat. 251, 337 (1997).

18Separate payment for telehealth services in Medicare fee-for-service are limited to those 

on CMS’s approved list of telehealth services. Plans within Medicare Advantage—the 

Medicare managed care program—must cover the same telehealth services as those 

provided through fee-for-service, and the plans must include these costs in their annual 

bid amounts. However, Medicare Advantage plans can provide additional telehealth 

benefits not on CMS’s approved list to their beneficiaries by using rebate dollars or 

charging beneficiaries a supplemental premium. Plans must receive CMS approval in 

order to provide the additional telehealth benefits.

Medicare Telehealth and 

Remote Patient Monitoring 

Requirements
Page 8 GAO-17-365 Telehealth and Remote Patient Monitoring

example, separate payment may be made for services used to remotely 

monitor patients’ conditions, such as services that use devices to monitor, 

record, and relay data on a patient’s heart activity to a provider for 

analysis. Additionally, Medicare pays for remote services as bundled 

parts of other services, such as elements of monthly care management 

services.

While telehealth visits with providers are conducted from a separate site, 

Medicare requires that the patient be physically present at a medical 

facility such as a hospital, rural health clinic, or skilled nursing facility—

referred to as the originating site—during the telehealth service.19 Eligible 

providers who are furnishing Medicare telehealth services are located at a 

separate site, known as the distant site, and these providers submit 

claims in the service area where their distant site is located.20 The 

originating site is paid a facility fee—about $25 in calendar year 2017—

under the Medicare Physician Fee Schedule for each telehealth service, 

and the distant site provider is paid the same rate for services delivered 

via telehealth as they would be paid for the in-person service, as required 

by statute.21 (See fig. 1.)

 19By statute, originating sites are limited to those located in rural health professional 

shortage areas, counties not included in a metropolitan statistical area, and sites 

participating in a federal telehealth demonstration project (referred to as telemedicine 

demonstration projects in statute) approved by or receiving funding from the Secretary of 

Health and Human Services as of December 31, 2000. Eligible originating sites are a 

physician or provider office, a critical access hospital, a rural health clinic, a federally 

qualified health center, a hospital, a hospital-based or critical access hospital-based renal 

dialysis center or satellites, a skilled nursing facility, and a community mental health 

center.

20Eligible telehealth providers in Medicare are physicians, physician assistants, nurse 

practitioners, clinical nurse specialists, certified registered nurse anesthetists, nursemidwives, clinical social workers, clinical psychologists, and registered dietitians or 

nutrition professionals.

21Medicare pays for physician and other health professional services based on a list of 

services and their payment rates, called the Physician Fee Schedule.
Page 9 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 1: Example of Telehealth Use in Medicare

Note: Medicare Administrative Contractors (MAC) process and pay Medicare claims in specific 

geographic jurisdictions. The MACs review claims and identify and prevent improper payments for 

Medicare services, including telehealth.

a

Medicare requires that the patient be physically present at a medical facility—referred to as the 

originating site—such as a hospital, rural health clinic, or skilled nursing facility during the telehealth 

service.

b

Eligible providers who are furnishing Medicare telehealth services are located at a separate site, 

known as the distant site.

CMS does not limit the use of telehealth and remote patient monitoring in 

Medicaid, which has around 70 million enrollees. Therefore, individual 

states determine any restrictions and limitations. For example, states 

have the option to determine

• whether to cover telehealth;

• what types of telehealth to cover;

• how it is provided or covered;

• which types of telehealth providers may be covered or reimbursed, as 

long as such providers are recognized and qualified according to 

Medicaid statute and regulation; and

Medicaid, DOD, and VA 

Telehealth and Remote 

Patient Monitoring 

Requirements
Page 10 GAO-17-365 Telehealth and Remote Patient Monitoring

• how much to reimburse for telehealth services, as long as such 

payments do not exceed other requirements.22

States are not required to submit a separate state plan amendment to 

CMS for coverage or reimbursement of telehealth services if they decide 

to reimburse for telehealth services the same way that they pay for faceto-face services.23 However, states must submit a separate 

reimbursement state plan amendment if they want to reimburse for 

telehealth services or components of telehealth differently than they 

reimburse for face-to-face services.

DOD, which serves around 9.4 million beneficiaries, allows telehealth 

through live videoconferencing between the provider and patient at 

different locations.

24 DOD does not have restrictions on the services that 

can be provided through its direct care component.

25 Broad types of 

allowable services include health assessments, treatments, diagnoses, 

interventions, and consultations. Different categories of providers are 

allowed to use telehealth and are not required to be individually licensed 

in the state where the patient—or originating site—is located. These 

providers include members of the Armed Forces, other DOD uniformed 

providers, civilian DOD employees, personal services contractors, and 

National Guard providers who are performing training or duty in response 

to an actual or potential disaster.26

 22For example, there are maximum payment amounts—referred to as the federal upper 

payment limit—that the federal government will provide in matching funds for 

reimbursement for services under Medicaid.

23Each state has a Medicaid state plan—approved by CMS—that describes, among other 

things, the services and populations that are covered under the state’s Medicaid program.

24DOD also uses asynchronous telehealth, called store-and-forward, that involves the 

capture of diagnostic images, sounds, and data that are interpreted at a later time and at a 

different location by a qualified diagnostician.

25DOD’s direct care component provides care in military hospitals and clinics, which are 

referred to as military treatment facilities. DOD’s purchased care, which is care provided 

through networks of civilian providers, limits services that can be provided via telehealth to 

clinical consultations, office visits, individual psychotherapy, psychiatric diagnostic 

interview examination, pharmacologic management, and end-stage renal disease related 

services when appropriate and medically necessary.

26Providers not covered in these categories are required to be licensed in the state where 

the originating site is located and in the state in which the provider is located when 

providing such services.
Page 11 GAO-17-365 Telehealth and Remote Patient Monitoring

DOD allows a range of eligible originating sites for telehealth. In addition 

to military treatment facilities, eligible originating sites include VA medical 

centers and clinics; installations, armories, or other non-medical fixed 

DOD locations; DOD mobile telehealth platforms; civilian sector hospitals 

and clinics; and contracted provider offices. In February 2016, DOD 

approved the patient’s home as an originating site for telehealth services 

from providers located in a military treatment facility or other designated 

facility in DOD’s direct care component.27

DOD also utilizes remote patient monitoring devices to provide care for 

eligible beneficiaries for a range of services. These services include the 

diagnosis and treatment of cardiac conditions, including ambulatory blood 

pressure monitoring and pacemakers, and continuous glucose monitoring 

for patients with diabetes. According to DOD officials, the department 

does not have policies that specifically govern the use of remote patient 

monitoring devices, but instead DOD leaves the determination of use to 

clinical practice guidelines or to professional society guidance or 

recommendations.

VA, which serves about 6.7 million patients, allows the use of telehealth 

via videoconferencing technologies to enable providers to assess, treat, 

and provide care to a patient remotely.28 VA also allows remote patient 

monitoring using mobile and in-home technologies assigned to veterans 

 27In addition to the patient’s home, DOD allows telehealth services for any “other patient 

location” that is deemed appropriate by the treating provider in DOD’s direct care 

component. Among other requirements, the telehealth provider must be privileged at the 

distant site and must inform the patient’s military treatment facility or primary care 

manager of the care delivered by telehealth. Privileging is the process that health care 

organizations employ to authorize providers to provide specific services to their patients. 

In the case of DOD’s purchased care, the originating site must be located where the 

authorized provider normally offers professional medical or psychological services, such 

as the provider’s office.

28VA also uses store-and-forward telehealth, which uses devices to capture and store 

images, sounds, or data that are then forwarded to clinical caregivers for asynchronous 

review and interpretation.
Page 12 GAO-17-365 Telehealth and Remote Patient Monitoring

based on individual needs.29 According to officials, VA does not restrict 

the use of telehealth or remote patient monitoring by type of service, 

provider, or location. Telehealth in VA can take place in various 

originating and distant site locations throughout the country, such as 

between two VA medical centers; a VA medical center and a communitybased outpatient clinic; two community-based outpatient clinics; from the 

provider’s site and the veteran’s home, a community living center, or a 

contract nursing home; and a provider’s home and sites such as a VA 

medical center or community-based outpatient clinic. In recent years, VA 

has taken steps to increase the use of telehealth. As part of VA’s fiscal 

year 2009 to fiscal year 2013 telehealth transformational initiative, VA 

recruited over 970 telehealth clinical technicians and purchased 

equipment for over 900 sites of care.

Table 1 summarizes the use of telehealth and remote patient monitoring 

in Medicare, Medicaid, DOD, and VA health programs.

 29The remote patient monitoring technologies include VA-provided hub devices placed in 

the veteran’s home, as well as mobile platforms for use with the veteran’s own device. 

The VA-provided hub devices can receive and transmit data via a landline phone, or in 

homes without a landline via a cellular modem integrated with the device, or by using the 

veteran’s personal computer. Mobile platforms include interactive voice response, which 

allows veterans to use their own landline or cell phone to receive and transmit responses 

using voice and keypad entry, and web-enabled technology, allowing veterans to use their 

own smartphone, computer, or tablet to access a secure VA vendor website for data 

transmission.
Page 13 GAO-17-365 Telehealth and Remote Patient Monitoring

Table 1: Summary of Federal Agency Telehealth Services and Originating Sites 

Federal agency Telehealth services Originating sites

Centers for Medicare & 

Medicaid Services 

(CMS)

Medicare Medicare pays for the 81 telehealth 

services on CMS’s list of telehealth 

services as of 2016.

For sites located in a rural health professional 

shortage area or a county that is not included 

in a Metropolitan Statistical Area, Medicare 

pays for telehealth used at the following 

locations:

a

• physician or provider office,

• critical access hospital,

• rural health clinic,

• federally qualified health center,

• hospital,

• hospital-based or critical access

hospital-based renal dialysis center or 

satellites,

• skilled nursing facility, and

• community mental health center.

Medicaid Services covered differ depending on 

the state. According to CMS officials, 

CMS does not have any statutory or 

regulatory requirements for telehealth 

use in Medicaid. 

CMS does not limit telehealth use in Medicaid. 

Restrictions on use vary by state.

Department of Defense 

(DOD)

DOD does not limit the services 

allowed for telehealth use within its 

direct care component.

b

Outside of military treatment facilities, 

originating sites are allowed at patient 

locations that are deemed appropriate by the 

treating provider in DOD’s direct care 

component, including the patient’s home.

According to officials, telehealth services are 

not limited to certain geographic areas, such 

as rural locations.

Department of Veterans 

Affairs (VA)

According to officials, VA does not limit 

the services providers can offer via 

telehealth.

According to officials, VA does not limit the 

locations where telehealth services may be 

offered.

Sources: CMS, DOD, and VA. | GAO-17-365

Note: The term “originating site” refers to the location where the patient is located while receiving a

telehealth service.

a

Medicare also pays for telehealth use for entities that participate in a federal telehealth 

demonstration project (referred to as telemedicine demonstration projects in statute) approved by or 

receiving funding from the Secretary of Health and Human Services as of December 31, 2000.

b

DOD’s direct care component provides care in military hospitals and clinics, which are referred to as 

military treatment facilities. DOD’s purchased care, which is care provided through networks of civilian 

providers, limits services that can be provided via telehealth to clinical consultations, office visits, 

individual psychotherapy, psychiatric diagnostic interview examination, pharmacologic management, 

and end-stage renal disease related services when appropriate and medically necessary. 

Additionally, for purchased care, the originating site must be located where the authorized provider 

normally offers professional medical or psychological services, such as the provider’s office.
Page 14 GAO-17-365 Telehealth and Remote Patient Monitoring

Our review of available data shows that low proportions of beneficiaries 

received care through telehealth in Medicare, Medicaid, VA, and DOD—

from less than 1 percent of beneficiaries in Medicare and DOD to 12

percent in VA—while the types of services available through these 

technologies varies. Data on use of remote patient monitoring are not 

aggregated for analysis in Medicare and are not available in selected 

Medicaid states, and limited data are available for DOD and VA.

Available calendar year 2014 data show that Medicare providers used 

telehealth services for a small proportion of beneficiaries and relatively 

few services. An analysis of Medicare claims data by MedPAC shows that 

about 68,000 Medicare beneficiaries—0.2 percent of Medicare Part B feefor-service beneficiaries—accessed services using telehealth.30 MedPAC 

also found that 10 states accounted for 42 percent of all Medicare 

telehealth visits, with South Dakota, followed by Iowa and North Dakota, 

accounting for the highest use—more than 20 telehealth services were 

provided per 1,000 fee-for-service beneficiaries.31 As of 2016, Medicare 

pays for 81 telehealth services. (See app. III for a list of health care 

services CMS has added or denied for inclusion on the Medicare list of 

telehealth services.)

According to MedPAC, beneficiaries accessing telehealth averaged about 

three telehealth visits per person per year in calendar year 2014, and 

Medicare spent an average of $182 per beneficiary, for a total of about 

$14 million. The majority of telehealth visits—62 percent—were for 

beneficiaries younger than 65 years old.32 The most common telehealth 

visits in calendar year 2014 were for evaluation and management 

services (66 percent), followed by psychiatric visits (19 percent).

 30See Medicare Payment Advisory Commission, Report to the Congress: Medicare and 

the Health Care Delivery System. Part B services include physician and outpatient 

hospital services.

31The other seven states are—in rank order of use of telehealth per 1,000 beneficiaries—

Wyoming, Nebraska, Minnesota, Missouri, Montana, Texas, and Oklahoma. 

32Medicare provides health care coverage for certain individuals with disabilities and 

individuals with end-stage renal disease, in addition to people age 65 or older.

Available Data Show 

Low Proportions of 

Beneficiaries 

Accessing Telehealth; 

Limited Data Are 

Available on Remote 

Patient Monitoring

Medicare
Page 15 GAO-17-365 Telehealth and Remote Patient Monitoring

MedPAC reported that physicians and nurse practitioners were the most 

common providers participating in telehealth visits in calendar year 2014 

and, of all providers, behavioral health clinicians, including psychiatrists,

made up 62 percent of providers at distant sites.33 According to MedPAC, 

a small proportion of providers accounted for the majority of telehealth 

visits in calendar year 2014. Ten percent of distant sites providers 

accounted for 69 percent of telehealth claims.

According to officials, because CMS does not have a separate category 

for remote patient monitoring services, as it does with telehealth, and 

these services may be bundled with other services, CMS has not 

conducted a separate analysis of remote patient monitoring services. 

Therefore, the number of Medicare beneficiaries who use this service is 

unknown. While the number of beneficiaries who use remote patient 

monitoring is not identified, MedPAC reported information on Medicare 

spending on remote patient monitoring for selected services. Specifically,

MedPAC reported that Medicare spent $119 million on remote cardiac 

monitoring services for 265,000 beneficiaries in calendar year 2014.34

MedPAC also reported that in calendar year 2014, Medicare spent $70 

million on remote patient monitoring for 639,000 beneficiaries to remotely 

monitor heart rhythms through implantable cardiac devices, such as 

pacemakers, and to evaluate the function of these devices.

In Medicaid, the use of telehealth and remote patient monitoring varies by 

state. We interviewed officials from six states and among these officials, 

the ones from states that were generally more rural than urban said they 

used telehealth and remote patient monitoring more frequently than 

officials from more urban states. Officials from four states provided the 

following information on the use of telehealth and remote patient 

monitoring in their Medicaid program.

• A Connecticut official said that in the state, which has medical centers 

in-state and is close to multiple medical centers in other states, 

Medicaid uses telehealth in a limited capacity by only allowing 

 33The distant site is a separate location where the provider furnishing the telehealth 

service is located.

34These services were for mobile cardiac telemetry monitoring of patients to record the 

patient’s electrocardiographic rhythm using external, rather than implantable, devices. The 

data are sent via phone signal to a surveillance site, and a physician reviews the data and 

prepares a report.

Medicaid
Page 16 GAO-17-365 Telehealth and Remote Patient Monitoring

provider-to-provider consults via secure messaging in federally 

qualified health centers. According to this official, Connecticut 

Medicaid data show that the state spent $89,053 on 817 provider-toprovider consults in 2015. The official told us that Connecticut officials 

needed to be convinced that the use of telehealth would not lead to 

unnecessary utilization of services in order to expand telehealth 

reimbursement beyond these consults.

• In Illinois, officials told us that telehealth represented a very small 

portion of the overall Medicaid budget and was used primarily to 

provide psychiatric services. According to officials, less than $500,000 

of Illinois’ $20 billion in Medicaid spending in the state fiscal year 2015 

was for telehealth.

• Mississippi began reimbursing for telehealth and remote patient 

monitoring in January 2015. Mississippi telehealth data show that 

from January 2015 through June 2015 Medicaid expenditures were 

about $9,360 for 210 claims for 172 managed care patients and 

$13,218 for 222 claims for 184 fee-for-service patients. For remote 

patient monitoring during the same period, Mississippi Medicaid 

expenditures were about $27,634 for 292 claims for 158 managed 

care patients and $4,969 for 99 claims for 68 fee-for-service patients.

• Montana officials told us they have used telehealth as a tool to help 

patients see both in-state and out-of-state specialists remotely, as 

there is limited access to specialists in the state. According to state 

officials, Montana’s Medicaid spending on telehealth increased from 

state fiscal years 2013 through 2015. Specifically, according to 

officials, Montana’s Medicaid program spent about $284,675 for 3,218 

telehealth distant site claims related to telehealth services provided in 

state fiscal year 2015, which is an increase from about $132,194 for 

1,841 distant site claims in state fiscal year 2013. According to 

officials, Montana’s Medicaid program reimbursed the site where the 

patient is located about $3,438 for 260 originating site claims in state 

fiscal year 2015, with psychiatric services accounting for the largest 

share of the state’s Medicaid telehealth expenditures that year.

For more details on telehealth and remote patient monitoring use in

Medicaid in the six selected states, see appendix IV.
Page 17 GAO-17-365 Telehealth and Remote Patient Monitoring

Fiscal year 2015 data show 25,389 DOD beneficiaries—or about 0.3 

percent—received care through telehealth.35 The most commonly offered 

telehealth services were behavioral health/psychiatry services, which 

accounted for approximately 80 percent of all telehealth encounters in 

fiscal year 2015, followed by dermatology, cardiology, and pediatric 

services. According to officials, DOD data also show that the top five 

locations in fiscal year 2015 for the provision of telehealth services were 

San Antonio, Texas; Fort Shafter, Hawaii; Fort Meade, Maryland; Joint 

Base Lewis-McChord, Washington; and Landstuhl, Germany. According 

to DOD officials, of these locations, the surrounding areas of San Antonio, 

Fort Shafter, and Joint Base Lewis-McChord include zip codes that are 

considered rural or have an area serviced by a sole community hospital.36

DOD has also used provider-to-provider e-consultations, which, according 

to a DOD official, allow providers to give consults to other providers who 

are deployed or stationed in remote areas, making it easier for providers 

to consult with one another even when separated by distance. According 

to officials, DOD also uses remote patient monitoring devices—such as 

remote pacemaker monitoring and sleep study monitors—to varying 

degrees across military treatment facilities. DOD officials noted that the 

agency conducted an Army pilot program using remote patient monitoring 

for 51 soldiers with known or newly diagnosed Type 1 Diabetes. 

According to DOD officials, DOD is currently developing additional pilot 

programs for remote patient monitoring.

According to VA officials, VA provided telehealth services to more than 

702,000 veterans during fiscal year 2016, or approximately 12 percent of 

veterans enrolled in VA’s health care system. Of these veterans, 

approximately 45 percent were veterans living in rural areas with limited 

access to VA health care. Of these 702,000 veterans using telehealth, 

150,600 veterans used remote patient monitoring services at least once 

from October 2015 to September 2016.

VA documents show that VA uses telehealth and remote patient 

monitoring for a wide range of services. These services include mental 

health services, such as services for post-traumatic stress disorder; 

 35DOD telehealth also includes asynchronous telehealth, called store-and-forward, that 

involves the capture of diagnostic images, sounds, and data that are interpreted at a later 

time and at a different location by a qualified diagnostician.

36Sole community hospitals provide health care in rural areas or areas where similar 

hospitals do not exist. 

DOD

VA
Page 18 GAO-17-365 Telehealth and Remote Patient Monitoring

primary care; rehabilitation; speech and audiology services; eye care; 

dermatology services; specialty care; critical care; and care for chronic 

conditions such as diabetes, chronic heart failure, chronic obstructive 

pulmonary disease, hypertension, and depression. According to VA 

officials, providers from over 50 different specialties are using telehealth. 

VA officials noted that as of May 2016, the most common conditions for 

veterans using remote patient monitoring were hypertension (almost 

19,000 veterans) and diabetes (about 14,000 veterans).

CMS oversees telehealth payments as a part of its general efforts to 

prevent improper payments in Medicare.37 CMS relies on Medicare 

Administrative Contractors (MAC), which process and pay Medicare 

claims in specific geographic jurisdictions. The MACs review claims to, 

among other things, identify and prevent improper payments for Medicare 

services, including telehealth. According to CMS officials, similar to other 

services, CMS has directed the MACs to only approve and pay claims 

with a telehealth modifier if the claims meet the statutory and regulatory 

criteria for covered telehealth services.38

According to CMS officials, CMS does not conduct any enhanced 

oversight or fraud prevention specific to telehealth payments, though 

officials told us that if there were indications of inappropriate payments or 

fraud schemes related to telehealth payments, CMS would provide 

additional oversight for these claims. Telehealth represents a very small 

percentage of all Medicare claims.39 CMS requires the MACs to focus 

 37An improper payment is any payment that should not have been made or that was made 

in an incorrect amount (including overpayments and underpayments) under statutory, 

contractual, administrative, or other legally applicable requirements. This definition 

includes any payment to an ineligible recipient, any payment for an ineligible good or 

service, any duplicate payment, any payment for a good or service not received (except 

where authorized by law), and any payment that does not account for credit for applicable 

discounts. Improper Payments Elimination and Recovery Act of 2012, Pub. L. No. 112-

248, § 3(a)(1), 126 Stat 2390 (codified at 31 U.S.C. § 3321 note).

38Distant site providers who furnish telehealth services bill for these services using a GT or 

GQ code modifier. The GT modifier is used if the telehealth service was provided via 

interactive audio and video telecommunications systems. The GQ modifier is used if the 

telehealth service was provided via an asynchronous telecommunications system. The 

site where the patient is located can also submit a separate originating site claim, which is 

indicated by the use of code Q3014.

39According to MedPAC, in calendar year 2014, Medicare paid 175,000 telehealth claims 

for a total of about $14 million, which is less than 0.01 percent of the approximately $257 

billion in total annual Medicare expenditures on Part B services in fiscal year 2014. 

CMS Uses Routine 

Claims Review 

Processes for 

Telehealth Payments 

and Is Examining 

Some Questionable 

Claims Identified by 

MedPAC
Page 19 GAO-17-365 Telehealth and Remote Patient Monitoring

their efforts on areas that pose the greatest financial risk to the Medicare 

program and where their efforts are likely to produce the best return on 

investment, which is consistent with federal internal controls.40

CMS officials told us that there are no payment incentives for a provider

to put a telehealth modifier on a non-approved telehealth service,

because the provider could receive payment for that service if it did not 

include the modifier and the service is payable under Medicare’s 

Physician Fee Schedule. That is, the payment to a distant site provider for 

a service on the approved telehealth list would be the same amount as 

the payment for the service if it were furnished in person. Adding a 

telehealth modifier incorrectly also increases the possibility that claim 

would be examined, CMS officials said, reducing the incentive to 

incorrectly add the telehealth modifier. CMS officials also said that for 

2017 Medicare is using a new place of service code to describe services 

furnished via telehealth. According to officials, the code is intended to 

better identify telehealth services.

However, MedPAC’s 2016 report, which examined Medicare telehealth 

claims, identified potential improper telehealth payments. Specifically, 

MedPAC reported that among the 175,000 Medicare telehealth claims 

paid in calendar year 2014, 55 percent, or about 95,000 claims, did not 

have a corresponding originating site claim.41 Because there was no 

originating site claim, it is unclear whether these beneficiaries received 

telehealth services in a location not permitted under the Medicare statute, 

such as the home, an originating site located in an urban area, or whether 

the claims were paid under a demonstration project or model. The 

Medicare statute requires beneficiaries to receive telehealth services in 

an originating site located in a rural area, as defined by Medicare for 

telehealth purposes, unless the site is part of a demonstration project or is 

participating in a Medicare model where telehealth location requirements 

are waived.

The absence of a corresponding originating site claim does not 

definitively indicate that the telehealth claims are improper, though it 

warrants further review. As a possible explanation for the difference in the 

number of originating site claims relative to distant site claims, CMS 

 40GAO-14-704G, GAO/AIMD-00-21.3.1.

41Calendar year 2014 Medicare data were the most complete year of data at the time of 

MedPAC’s review.
Page 20 GAO-17-365 Telehealth and Remote Patient Monitoring

officials suggested that if a facility does not frequently serve as an 

originating site, it may not find it worthwhile to submit a claim for the 

approximately $25 originating site fee. Additionally, there may be cases 

where a beneficiary receives multiple telehealth services in a single day, 

and in such cases, the telehealth encounter might include several 

services that are appropriately billed with several claims from the distant 

site provider, but only have a single originating site claim.

However, according to MedPAC, the absence of originating site claims 

may have occurred because some patients may have inappropriately 

received services in their homes or other locations not permitted under

the Medicare statute.

42 MedPAC also found that among the telehealth 

claims without corresponding originating site claims, 44 percent—or 

almost one-quarter of all telehealth claims made in calendar year 2014—

were associated with beneficiaries living in urban areas, which could 

indicate that the patients were receiving telehealth services at 

inappropriate originating sites.43 MedPAC officials told us that they 

identified one provider who conducted 2,000 telehealth visits in a single 

year, and all of those claims originated from an urban area.

When asked about MedPAC’s findings, CMS officials told us that as of 

January 2017, they are reviewing the MedPAC report. They further stated 

that the agency will take action on MedPAC’s findings, as warranted. This 

is consistent with federal standards for internal controls related to 

monitoring that call for managers to promptly evaluate findings from 

audits and other reviews—including those showing deficiencies—and 

determine and complete appropriate corrective actions.44

 42Medicare has published information for providers to guide the use of telehealth. For 

example, in December 2015, CMS released a publication providing information on 

Medicare telehealth rules and regulations, including eligibility criteria for originating sites. 

In March 2016, CMS released guidance for providers submitting claims to the MACs for 

telehealth services provided to the beneficiaries. The guidance includes an address for a 

website that provides an updated list of Medicare telehealth services.

43MedPAC reported in 2013 that some physician practices billed errantly for telehealth 

services for urban patients because their billing managers were unaware of Medicare’s 

location requirements for telehealth payment.

44GAO-14-704G, GAO/AIMD-00-21.3.1.
Page 21 GAO-17-365 Telehealth and Remote Patient Monitoring

Officials from selected associations representing providers and patients

rated the significance of certain factors that encourage the use of 

telehealth and remote patient monitoring in Medicare as well as factors 

that create barriers to their use. The officials reported that both telehealth 

and remote patient monitoring may improve or maintain quality of care in 

Medicare, but they rated concerns regarding payment and coverage 

restrictions as potential barriers. Officials with a payer association we 

selected generally agreed with the assessments of the selected provider

and patient associations.

Among the factors presented as potentially encouraging both telehealth 

and remote patient monitoring use in Medicare, officials from selected 

provider and patient associations most often rated the potential to 

improve or maintain quality of care as very or somewhat significant. (See 

fig. 2.) Officials from a provider association told us that telehealth can 

improve patient outcomes by facilitating follow-up to care. Additionally, an 

official from a patient association stated that remote patient monitoring is 

a helpful tool for treating patients with chronic disease.

Furthermore, officials from selected provider and patient associations 

more often rated alleviating provider shortages, convenience to patients, 

and coverage of services as very significant or somewhat significant 

factors that encourage both telehealth and remote patient monitoring use 

in Medicare. For example, officials from one provider association noted 

that provider and regional medical specialty shortages can be addressed 

through telehealth, potentially increasing productivity and ensuring ontime scheduling of appointments. Officials from another provider 

association reported that telehealth can increase convenience by 

shortening or eliminating travel times—which may lead to better 

adherence to recommended treatments and to patient satisfaction. 

Regarding remote patient monitoring, officials from a provider association 

explained that it can be an important tool for emergency department 

physicians to provide expertise to rural areas remotely, which could 

alleviate provider shortages.

Selected Associations 

Report Telehealth and 

Remote Patient 

Monitoring May 

Improve Care for 

Medicare 

Beneficiaries, but 

Cited Coverage and 

Payment Restrictions 

as Barriers

Selected Associations 

Cited the Potential to 

Improve or Maintain 

Quality of Care as a 

Significant Factor 

Encouraging the Use of 

Telehealth and Remote 

Patient Monitoring in 

Medicare
Page 22 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 2: Significance of Certain Factors That Encourage the Use of Telehealth and Remote Patient Monitoring in Medicare, 

According to Selected Provider and Patient Associations

Note: Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.

Less frequently identified factors cited by association officials that 

encourage telehealth and remote patient monitoring use are described in 

the following examples, and in appendix V.

• Officials from two selected provider associations told us that emerging 

Medicare payment structures—such as accountable care 
Page 23 GAO-17-365 Telehealth and Remote Patient Monitoring

organizations (ACO)—could alleviate concerns about overutilization in 

Medicare’s fee-for-service payment system.

45 The concern is that 

telehealth would be used in addition to, instead of in place of, face-toface visits.

• Officials from one selected provider association stated that remote 

patient monitoring use shows promise in lowering health care costs 

and avoiding unneeded emergency room visits, because it allows a 

provider to identify subtle changes in a patient’s condition and 

schedule an office visit before the patient’s condition deteriorates.

• Officials from a selected patient association said that remote patient 

monitoring can help patients and their caregivers save on 

transportation costs and help them avoid having to miss work.

Although officials from the payer association we selected did not rate the 

significance of the factors, they confirmed that improving or maintaining 

quality of care was a factor in encouraging the use of both telehealth and 

remote patient monitoring. For example, officials stated that telehealth 

has the potential to decrease hospital readmissions and use of intensive 

care units. These officials also identified alleviating provider shortages 

and providing convenience for the patient as encouraging the use of 

telehealth. Additionally, these officials noted that the ability of patients to 

use their own electronic devices—such as home computers or 

smartphones—could facilitate broader use of remote patient monitoring 

services.

Among the factors presented as potential barriers to the use of both 

telehealth and remote patient monitoring in Medicare, selected patient 

and provider associations most often rated cost increases or inadequate 

payment and coverage restrictions as very significant or somewhat 

significant. (See fig. 3.) Officials often linked their comments on payment 

with those regarding coverage restrictions. For example, officials from a 

provider association reported that Medicare’s telehealth policies for 

payment and coverage lag behind other payers due to the program’s 

statutory and regulatory restrictions. In particular, these restrictions limit 

the geographic and practice settings in which beneficiaries may receive 

 45ACOs are groups of physicians, hospitals, and other health care providers who 

voluntarily work together to give coordinated care to the Medicare patients they serve. See 

GAO, Medicare Value-Based Payment Models: Participation Challenges and Available 

Assistance for Small and Rural Practices, GAO-17-55 (Washington, D.C.: Dec. 9, 2016).

Selected Associations 

Cited Payment and 

Coverage Restrictions as 

Barriers to the Use of 

Telehealth and Remote 

Patient Monitoring in 

Medicare
Page 24 GAO-17-365 Telehealth and Remote Patient Monitoring

services, as well as the types of services that may be provided via 

telehealth and the types of technology that may be used.

Additionally, officials from another provider association described 

coverage as the single greatest barrier to the use of telehealth, adding 

that Medicare’s restrictions on the types of services covered by the 

program have prohibited its broader use. Regarding remote patient 

monitoring, officials from another provider association stated that 

Medicare’s valuation methodology for services results in low payment 

rates for remote patient monitoring, which these officials said remains a 

principal barrier to the use of these services. For more information on 

Medicare’s valuation of remote patient monitoring, see appendix VI.

Officials from selected provider and patient associations more often rated 

infrastructure requirements as a very significant or somewhat significant 

barrier to the use of both telehealth and remote patient monitoring in 

Medicare. For example, officials from one provider association and both 

patient associations we selected described access to sufficiently reliable 

broadband internet service as a barrier to telehealth use. Officials from 

both of the patient associations also mentioned the ability to access the 

technology necessary to use telehealth as a potential barrier to its use. 

Officials from two of these provider associations also described 

uncertainty around which remote patient monitoring products and 

services are most effective.
Page 25 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 3: Significance of Certain Barriers to the Use of Telehealth and Remote Patient Monitoring in Medicare, According to 

Selected Provider and Patient Associations

Note: Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.

Less frequently identified barriers to telehealth and remote patient 

monitoring use cited by selected provider and patient association officials 

are shown in the following examples, and in appendix V.

• Officials from both selected patient associations rated provider and 

patient training requirements as very significant barriers to the use of 

both telehealth and remote patient monitoring. Officials from one of 

these patient associations noted that training is important for patients, 

providers, and caregivers to help them understand the technology 

involved in using telehealth and remote patient monitoring.
Page 26 GAO-17-365 Telehealth and Remote Patient Monitoring

• Officials from both selected patient associations also rated cultural 

factors, such as language and technological literacy, as very 

significant barriers to the use of both telehealth and remote patient 

monitoring.

• Officials from four selected provider associations rated professional 

licensure issues as a very or somewhat significant barrier to the use 

of telehealth. Officials from one association mentioned states’ 

participation in the Interstate Medical Licensure Compact as a 

potential strategy to overcome telehealth licensure barriers.46

Although officials from the payer association we selected did not rate the 

significance of barriers to telehealth or remote patient monitoring use, 

they confirmed that cost increases and inadequate payment, as well as 

infrastructure requirements, are barriers to the use of these technologies. 

For example, officials cited as barriers equipment costs and the 

distribution of equipment to patients. Additionally, they discussed 

concerns about problems with the interoperability of platforms and 

devices used for telehealth.

47

 46The Interstate Medical Licensure Compact is a voluntary expedited pathway to licensure 

for physicians who wish to practice in multiple states.

47Interoperability is the ability of two or more systems or components to exchange 

information and to use the information that has been exchanged. See GAO, Electronic 

Health Records: DOD and VA Have Increased Their Sharing of Health Information, but 

More Work Remains, GAO-08-954 (Washington, D.C.: July 28, 2008).
Page 27 GAO-17-365 Telehealth and Remote Patient Monitoring

CMS has efforts underway that have the potential to expand the use of 

telehealth and remote patient monitoring in Medicare. First, CMS 

supports models and demonstrations that offer alternative approaches to 

health care payment and delivery.48 Second, CMS’s new Medicare 

payment program allows participating clinicians to use telehealth, and to 

some extent remote patient monitoring, to help them achieve some of the 

goals of the payment program.

49

The Patient Protection and Affordable Care Act created the Innovation 

Center within CMS to test innovative payment and service delivery 

models to reduce Medicare, Medicaid, and state Children’s Health 

Insurance Program expenditures while preserving or enhancing the 

quality of care for beneficiaries of the programs.50 The Innovation Center 

also supports Medicare demonstration projects, which study the likely 

impact of new methods of service delivery, coverage of new types of 

services, and new payment approaches on beneficiaries, providers, 

health plans, states, and the Medicare trust funds. The Innovation Center 

has the authority to waive Medicare telehealth requirements as part of its 

efforts to implement and test these models and, as allowed by other 

statutory authorities, as part of testing demonstrations.

 48Models are new payment and service delivery structures developed by CMS under the 

authority of section 1115A of the Social Security Act. Demonstration projects study the 

likely impact of new methods of service delivery, coverage of new types of services, and 

new payment approaches on beneficiaries, providers, health plans, states, and the 

Medicare trust funds. These demonstration projects are established under other statutory 

authorities. 

49The Merit-based Incentive Payment System applies to eligible clinicians, defined as 

physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified 

registered nurse anesthetists, and groups that include such clinicians who bill under 

Medicare Part B. While we refer to “providers” elsewhere in our report, we use the term 

“clinicians” when discussing the Merit-based Incentive Payment System.

50Pub. L. No. 111-148, §§ 3021, 10306, 124 Stat. 119, 389, 939 (codified at 42 U.S.C. § 

1315a).

CMS Has Various 

Efforts Underway 

That Have the 

Potential to Expand 

the Use of Telehealth 

and Remote Patient 

Monitoring in 

Medicare

CMS Models and 

Demonstrations
Page 28 GAO-17-365 Telehealth and Remote Patient Monitoring

According to CMS, telehealth waivers may broaden access to telehealth 

services, and CMS’s Innovation Center has used its authority, and other 

statutory authorities as applicable, to waive Medicare telehealth 

requirements for eight models and demonstrations in certain 

circumstances.51 Specifically, CMS’s Innovation Center waived certain 

requirements regarding the geographic location or types of permitted sites 

at which beneficiaries can receive telehealth services for four models:

• Next Generation ACOs are groups of doctors, hospitals, and other 

health care providers and suppliers who come together voluntarily to 

provide coordinated, high-quality care at lower costs to their Medicare 

patients.52

• Two Bundled Payments for Care Improvement models link payments 

for the multiple services beneficiaries receive during an episode of 

care.53 Under this initiative, organizations enter into payment 

arrangements that include financial and performance accountability 

for episodes of care.

• The Comprehensive Care for Joint Replacement Model aims to 

support better and more efficient care for beneficiaries undergoing hip 

and knee replacements, which are the most common inpatient 

surgeries for Medicare beneficiaries.54

Additionally, CMS officials told us that three Episode Payment Models will 

have telehealth waivers removing Medicare’s geographic and permitted 

site telehealth requirements beginning sometime in calendar year 2017 

and will pay providers for care based on the following conditions treated:

• acute myocardial infarction,

 51The Social Security Act provides authority for the Secretary of Health and Human 

Services to waive Medicare payment requirements as may be necessary for the 

Innovation Center to test payment and delivery service models. According to CMS 

officials, the statutory authorities of certain demonstrations have provided similar authority 

to waive Medicare telehealth requirements.

52As of January 2017, there were 45 Next Generation ACO model participants.

53When we refer to the Bundled Payments for Care Improvement Model, we are referring 

to model two, Retrospective Acute & Post Acute Care Episode, and model three, 

Retrospective Post Acute Care Only, which are the two Bundled Payments for Care 

Improvement models with access to the telehealth waiver. As of January 2017, model two 

has 577 participants and model three has 779 participants.

54Comprehensive Care for Joint Replacement Model participation is required in 67 

Metropolitan Statistical Areas.
Page 29 GAO-17-365 Telehealth and Remote Patient Monitoring

• coronary artery bypass grafts, and

• surgical hip and femur fractures.55

Furthermore, in one demonstration that aims to develop and test new 

models of integrated health care in sparsely populated rural counties—the 

Frontier Community Health Integration Project Demonstration—CMS 

allows participants to receive cost-based payments for telehealth when 

their location serves as the originating site, rather than the approximately 

$25 fixed fee that CMS otherwise pays originating sites.56 See table 2 for 

more information on the Medicare telehealth requirements waived for 

these models and demonstrations.

CMS officials told us that the Innovation Center also has the authority to 

waive requirements regarding payment for telehealth services for 

payment and delivery service models, but that the Innovation Center 

identified waiving requirements regarding the originating site as the best 

way to provide broader access to telehealth.57 The Innovation Center 

could potentially waive other telehealth requirements if it decided to do so 

in the future.

 55According to CMS officials, the Acute Myocardial Infarction Model and the Coronary 

Artery Bypass Graft Model will be implemented in 98 Metropolitan Statistical Areas, 

accounting for approximately 1,127 hospitals, and the Surgical Hip and Femur Fracture 

Treatment Model will be implemented in the 67 Metropolitan Statistical Areas where the 

Comprehensive Care for Joint Replacement Model is also occurring, accounting for 866 

hospitals.

56The Frontier Community Health Integration Project Demonstration has 10 rural health 

care participants, and of those, 8 have telehealth as a demonstration intervention tool. 

CMS officials told us that CMS initially explored implementing a store-and-forward waiver 

for this demonstration, which would have allowed providers to, for example, take a photo 

of a skin condition, then send that photo to a dermatologist at a distant site for review. 

CMS officials told us they determined that it was not operationally feasible to implement 

that waiver within the demonstration period. 

57CMS officials told us that CMS also has the authority to waive some telehealth 

requirements for other demonstration projects through other statutory authority. 
Page 30 GAO-17-365 Telehealth and Remote Patient Monitoring

Table 2: Medicare Telehealth Requirements Waived for Selected Models and Demonstrations

Requirement Change in Medicare telehealth requirement under waiver Applicable models and 

demonstrations

Originating site 

geography 

This waiver removes the requirement that telehealth only occur in

• a rural health professional shortage area,

• a county that is not included in a Metropolitan Statistical Area, or

• an entity that participates in a federal telehealth demonstration 

project (referred to as telemedicine demonstration projects in 

statute) approved by or receiving funding from the Secretary of 

Health and Human Services as of December 31, 2000.

Bundled Payments for Care 

Improvement Modela

Comprehensive Care for Joint 

Replacement Model

Episode Payment Modelsb

Next Generation Accountable 

Care Organizations 

Originating site type The waiver allows for telehealth services to be furnished in the patient’s 

home or place of residence and eliminates the requirement that the 

patient receiving telehealth services must be at one of the specified 

originating sites:

• physician or provider office,

• critical access hospital,

• rural health clinic,

• federally qualified health center,

• hospital,

• hospital-based or critical access hospital-based renal dialysis center 

or satellites,

• skilled nursing facility, or

• community mental health center.

The waiver eliminates the requirement to pay originating site fees when 

telehealth services are provided in the patient’s home.

Comprehensive Care for Joint 

Replacement Model

Episode Payment Modelsb

Next Generation Accountable 

Care Organizations

Originating site facility fee The waiver allows participants to receive cost-based payment for 

telehealth when they are the originating site, rather than the 

approximately $25 set fee for originating sites.

Frontier Community Health 

Integration Project 

Demonstration

Source: GAO analysis of Medicare statute and Centers for Medicare & Medicaid Services (CMS) regulations. | GAO-17-365

Note: The term “originating site” refers to the location where the patient is located while receiving a 

telehealth service.

a

The Bundled Payments for Care Improvement Model refers in this case only to Bundled Payments 

for Care Improvement models two and three.

b

Episode Payment Models refer to three models for episodes of care surrounding (1) acute 

myocardial infarction, (2) coronary artery bypass graft, and (3) surgical hip/femur fracture treatment. 

CMS officials told us that these models would begin sometime in calendar year 2017.
Page 31 GAO-17-365 Telehealth and Remote Patient Monitoring

In calendar year 2015, 15 Next Generation ACOs submitted 

implementation plans that detailed their proposed strategies to implement 

the telehealth waiver.

58 Eleven out of the 15 expected to use telehealth to 

provide increased access to specialty providers.59 For example, one 

participant reported that it would use telehealth to establish a virtual 

network of specialists who could provide telehealth consultations to 

patients in areas such as cardiology, rheumatology, and psychiatry. In 

addition, 8 out of 15 Next Generation ACOs included plans to use 

telehealth to improve care for patients with chronic conditions.60 For 

example, one participant planned to use telehealth to connect 

beneficiaries who have chronic diseases—such as congestive heart 

failure, diabetes, and pulmonary diseases—with their care team, including 

specialty providers.

As table 3 shows, the Innovation Center models and demonstration with 

waivers are in various stages of implementation, and their participants are 

using telehealth to varying degrees.

 58There were 18 Next Generation ACOs operating in calendar year 2016, and of those, 15 

provided CMS with implementation plans to use telehealth waivers. CMS officials told us 

that implementation plans were also required for the Frontier Community Health 

Integration Project Demonstration, but not for the other models with telehealth waivers. 

59The remaining four Next Generation ACOs may plan to provide increased access to 

specialty providers through the use of telehealth; however, their implementation plans did 

not explicitly state that this was the ACOs’ intent under the waiver. 

60The remaining seven Next Generation ACOs may plan to use telehealth to improve care 

for patients with chronic conditions; however, their implementation plans did not explicitly 

state that this was the ACOs’ intent under the waiver.
Page 32 GAO-17-365 Telehealth and Remote Patient Monitoring

Table 3: Telehealth Use by Selected Models and Demonstrations with Waivers of Certain Medicare Requirements

Model or 

demonstration 

Time period of 

services

Number of Medicare telehealth 

services provided

Additional information

Bundled Payments for 

Care Improvement 

Modela

October 2013-June 

2015

7 CMS officials told us that during this period model 

participants performed a total of 166,000 services.

Next Generation 

Accountable Care 

Organization (ACO) 

Model

January 2016-June 

2016

1,422 According to CMS officials, telehealth services 

were concentrated among a few ACOs. One ACO 

accounted for more than half of all the telehealth 

claims, and five each had more than 50 telehealth 

claims.

CMS officials said that around one-third of the 

telehealth services provided were for beneficiaries 

residing in urban areas, and the officials said they 

could attribute this use to the waiver.

Comprehensive Care 

for Joint Replacement 

Model

April 2016-September 

2016

0 CMS officials said that as of January 2017 these 

data were still preliminary and may not include all 

claims for care that occurred between April 2016 

and September 2016. As a result, there may be 

claims for telehealth services delivered as part of 

the Comprehensive Care for Joint Replacement 

Model during that time frame that are not yet 

reflected in CMS’s claims data.

Frontier Community 

Health Integration 

Project 

Demonstration

n/a n/a CMS officials told us that as of January 2017, they 

did not have data on the utilization of the 

originating site facility fee waiver, as the 

demonstration has only been operational for a few 

months. 

Episode Payment 

Modelb n/a n/a CMS officials told us that these models would begin sometime in calendar year 2017.

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) reports and interviews. | GAO-17-365

Note: n/a = not applicable.

a

The Bundled Payments for Care Improvement Model refers in this case only to Bundled Payments 

for Care Improvement models two and three.

b

Episode Payment Models refer to three models for episodes of care surrounding (1) acute 

myocardial infarction, (2) coronary artery bypass graft, and (3) surgical hip/femur fracture treatment.

In addition to the models and demonstrations in which CMS waives 

certain telehealth requirements, other models and demonstrations may 

affect the use of telehealth, as described in the following examples.

• Under its Health Care Innovation Award program, CMS funds 

cooperative agreements that the agency identifies as the most 

compelling new ideas to deliver better health, improve care, and lower 
Page 33 GAO-17-365 Telehealth and Remote Patient Monitoring

costs to Medicare, Medicaid, and state Children’s Health Insurance 

Program beneficiaries.61 Some of these projects include initiatives 

focused on telehealth and remote patient monitoring.62 For example, 

one award supported efforts to use telehealth and remote patient 

monitoring to provide care for urban and rural Medicare patients 

receiving intensive care. An evaluation of this awardee found the 

effort was associated with a reduction in hospital readmissions.63

• According to CMS documents, in the Initiative to Reduce Avoidable 

Hospitalizations among Nursing Facility Residents—which aims to 

improve the quality of care for individuals residing in long-term care 

facilities by reducing avoidable hospitalizations—a participant plans to 

use telehealth to evaluate nursing home residents whose conditions 

worsen at night when physicians are not present.64

• The Independence at Home Demonstration, which tests a payment 

incentive and service delivery model that uses primary care teams to 

provide in-home primary care to Medicare beneficiaries with multiple 

chronic conditions, includes practices that have the ability to use 

remote monitoring and mobile diagnostic technology with their 

patients.65

For more examples of how telehealth and remote patient monitoring may 

be used in models and demonstrations, see appendix VII.

 61A cooperative agreement is a legal instrument used to provide financial support when 

substantial interaction is expected between a federal agency and a state, local 

government, or other recipient carrying out the funded activity. 

62Round one of the Health Care Innovation Awards funded up to $1 billion in awards over 

three years through cooperative agreements. A 2015 CMS report shows that 17 of the 

agency’s 108 round one Health Care Innovation Awards include a telehealth or remote 

patient monitoring component. Department of Health and Human Services, Center for 

Medicare & Medicaid Innovation, Health Care Innovation Awards (HCIA) Meta-Analysis 

and Evaluators Collaborative, Annual Report Year 1.

63Round two of the Health Care Innovation Awards funded up to $360 million in awards. 

CMS officials told us that of the 39 round two Health Care Innovation Awards, 7 focused 

on telehealth. The officials told us the awards were underway and that evaluation results 

are not yet available. 

64As of January 2017, there were seven organizations selected for the Initiative to Reduce 

Avoidable Hospitalizations among Nursing Facility Residents. 

65This demonstration supports home-based primary care for Medicare beneficiaries with 

multiple chronic conditions. 
Page 34 GAO-17-365 Telehealth and Remote Patient Monitoring

Beginning in 2017, CMS will implement the Quality Payment Program, 

which will include a new Medicare payment program—the Merit-based 

Incentive Payment System—for physicians and other clinicians. The 

Merit-based Incentive Payment System will consolidate components of 

programs currently used to tie payments to quality and provide incentives 

for quality, resource use, clinical practice improvement activities, and 

advancing care information through the meaningful use of electronic 

health record technology.66 Under this payment program, clinicians can 

use telehealth in certain ways to meet the criteria in the program’s 

improvement activities performance category, which can help clinicians 

improve their performance under the payment program.

67 For example, 

clinicians could use telehealth to coordinate care and, in some cases, to 

reach patients in remote locations. Additionally, there are some instances 

when clinicians can use remote patient monitoring to meet Merit-based 

Incentive Payment System goals—for example, using home monitoring to 

remotely gather information to determine a patient’s proper dose of blood 

thinning medication. According to CMS officials, clinicians using 

telehealth and remote patient monitoring for these purposes do not have 

to bill Medicare for the service in order to receive credit for it under the 

Merit-based Incentive Payment System, and these services can count for 

credit under the improvement activities performance category regardless 

of whether they meet the statutory telehealth requirements. However, if 

clinicians want to bill Medicare for these services, the service must meet 

Medicare’s statutory requirements for payment.

We provided a draft of this report to HHS, DOD, and VA for review and 

comment. These departments provided technical comments, which we 

incorporated as appropriate. 

We also provided relevant draft portions of this report to stakeholders we 

interviewed. Specifically, we provided these excerpts to state Medicaid 

program officials for Connecticut, Illinois, Kansas, Mississippi, Montana, 

 6681 Fed. Reg. 77010. Components of the previously separate Physician Quality 

Reporting System, Physician Value-based Payment Modifier program, and Medicare 

electronic health record incentive program will be merged into the Merit-based Incentive 

Payment System so that payments for most physicians will reflect physician performance 

on both quality measures and electronic health record use. See GAO-17-55.

67Improvement activities are those that support broad aims within health care delivery, 

including care coordination, beneficiary engagement, population management, and health 

equity.

Merit-based Incentive 

Payment System

Agency and ThirdParty Comments
Page 35 GAO-17-365 Telehealth and Remote Patient Monitoring

and Oregon; representatives of selected provider, patient, and payer 

associations; and officials from selected private payers. Not all of the 

stakeholders responded. One state and one association confirmed that 

the information we provided was accurate. In addition, three states, four

associations, and three private payers provided technical comments, 

which we incorporated as appropriate. 
Page 36 GAO-17-365 Telehealth and Remote Patient Monitoring

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Health and Human Services, Secretary of 

the Department of Defense, Secretary of the Department of Veterans 

Affairs, and to other interested parties. In addition, the report is available 

at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or YocomC@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix VIII.

Carolyn L. Yocom

Director, Health Care
Page 37 GAO-17-365 Telehealth and Remote Patient Monitoring

List of Requesters

The Honorable Orrin Hatch

Chairman

The Honorable Ron Wyden

Ranking Member

Committee on Finance

United States Senate

The Honorable Lamar Alexander

Chairman

The Honorable Patty Murray

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Greg Walden

Chairman

The Honorable Frank Pallone

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Kevin Brady

Chairman

The Honorable Richard Neal

Ranking Member

Committee on Ways and Means

House of Representatives
Appendix I: Use of Remote Patient Monitoring 

by Selected Private Payers

Page 38 GAO-17-365 Telehealth and Remote Patient Monitoring

As part of our work, we interviewed officials from health plans in the 

private insurance market (private payers) about the use of remote patient 

monitoring.1 This appendix provides the results of those interviews. 

Officials from three of the top private payers (based on market share) told 

us that providers can use remote patient monitoring in their health care 

systems when it is indicated for a patient’s condition.2

Officials from the three private payers told us they have limited data on 

the extent to which remote patient monitoring is used. They told us they 

did not have data available because, for example, remote patient 

monitoring services are usually part of a care management program in 

which charges are bundled and not billed and detailed separately. It is 

therefore difficult to distinguish remote patient monitoring services from 

services provided via telehealth, officials explained. Some of the health 

plans of these three private payers reimburse for remote patient 

monitoring on a fee-for-service basis, while others include it as part of the 

services offered through integrated delivery systems that do not 

reimburse for separate services.

Officials from one private payer explained that they want physicians to 

decide which patients, conditions, problems, and circumstances are most 

suited to remote patient monitoring. This private payer does not 

reimburse physicians on a fee-for-service basis, noting that incentives,

such as payment, can drive behavior. As an example, if the provider 

receives reimbursement based on the amount of monitoring, the provider 

may file more claims for monitoring, regardless of whether the use is 

driven by evidence-based care processes. Instead, officials from this 

private payer stated that their incentives focus on the care outcomes of 

physicians’ patients, and they pay physicians based on the quality of the 

outcomes by disease population. Officials explained that they are 

currently rolling out programs to track diabetic patients’ blood sugar by 

monitoring what they eat, the exercise they get, and how they live. 

Additionally, this private payer has been using remote patient monitoring 

for patients with heart failure for some time, and officials told us that data 

 1

Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as the home.

2

The three private payers we interviewed were in the top five payers by market share in 

the accident and health insurance industry based on the National Association of Insurance 

Commissioners’ 2015 report. See National Association of Insurance Commissioners, 2014 

Market Share Reports: For the Top 125 Accident and Health Insurance Groups and 

Companies by State and Countrywide (2015).

Appendix I: Use of Remote Patient 

Monitoring by Selected Private Payers
Appendix I: Use of Remote Patient Monitoring 

by Selected Private Payers

Page 39 GAO-17-365 Telehealth and Remote Patient Monitoring

gathered through monitoring of weight and blood pressure are good 

predictors of early deterioration of heart conditions. Similarly, this private 

payer has a program for patients with hypertension that monitors a 

patient’s stress level.

Officials from a second private payer stated that they reimburse for 

remote patient monitoring in a manner that is appropriate for the specific 

condition being treated. For example, they reimburse for cardiologic 

remote patient monitoring if the patient has symptoms that are indications 

for the use of monitoring. If the condition does not indicate cardiologic 

monitoring, the private payer does not reimburse for this monitoring. 

Officials from this second private payer said they are reimbursing for 

remote patient monitoring that is used in real time to monitor patients with 

one or more chronic conditions and for high-risk patients. For example, 

the service is used to monitor blood pressure for hypertension, weight 

changes for congestive heart failure, and real-time blood sugar for 

diabetes. According to these private payer officials, providers typically use 

remote patient monitoring in the short-term and episodically, or to 

retrospectively look at monitoring results to make a clinical decision. 

Remote patient monitoring is also used to connect health plan members 

with their care managers, and these managers can notify providers to 

intervene if the monitoring indicates a need. This private payer also has 

various pilot programs related to remote patient monitoring, including a

program for its members with varying levels of congestive heart failure.

Officials from the third private payer told us that if remote patient 

monitoring is indicated by a patient’s condition, then the provider can 

order its use. Some of the payer’s private plans are integrated delivery 

systems for overall care, and in these plans providers are not paid 

separately for remote patient monitoring. According to officials, their 

agreements with providers are designed to encourage providers to use 

data from all sources, such as claims information, electronic medical 

records, and remote patient monitoring. The private payer also contracts 

with accountable care organizations and enters into payment 

arrangements with provider groups.3 Those entities use remote patient 

monitoring and the information obtained through monitoring as part of 

their care management of patients. This private payer’s fee-for-service 

 3

Accountable care organizations are groups of physicians, hospitals, and other health care 

providers who voluntarily work together to provide coordinated care to the Medicare 

patients they serve.
Appendix I: Use of Remote Patient Monitoring 

by Selected Private Payers

Page 40 GAO-17-365 Telehealth and Remote Patient Monitoring

plans reimburse for remote patient monitoring services, including cardiac 

services.

Officials from all three private payers told us that there are challenges to 

using remote patient monitoring in the private sector. For example, 

officials from one private payer said that barriers to the use of remote 

patient monitoring can include the need to set up equipment in the 

patient’s home, interact with members with cognitive and physical 

disabilities and their caregivers, and address technical difficulties with the 

equipment.
Appendix II: Scope and Methodology for 

Identifying Factors Affecting the Use of 

Telehealth and Remote Patient Monitoring

Page 41 GAO-17-365 Telehealth and Remote Patient Monitoring

We administered a data collection instrument to selected associations 

representing providers, patients, and payers to obtain information on the 

factors that encourage the use of telehealth and remote patient 

monitoring in Medicare or are barriers to their use. To develop the data 

collection instrument, we identified a list of potential factors and barriers 

based on background research and initial interviews with two groups with 

an interest in telehealth. Table 4 displays the list of factors that encourage 

use or are barriers to use as they appeared in the data collection 

instrument.1 For the purposes of the data collection instrument, we 

defined telehealth as clinical services that are provided remotely via 

telecommunications technologies, and we defined remote patient 

monitoring as a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.

Table 4: Potential Factors that Encourage the Use or Are Barriers to the Use of Telehealth or Remote Patient Monitoring in 

Medicare Used in the Data Collection Instrument

Potential factors that encourage or are barriersa If Yes, how significant is the factor that encourages or is a barrier?

Is this a factor that 

encourages or is a 

barrier (Y/N)?

Not Significant Somewhat 

Significant

Very Significant

Factors that encourage use

Alleviation of provider shortages/

scheduling problems

Convenience for the patient

Cost reduction

Coverage of services

Emerging Medicare payment structures or

waivers 

Enabling the use of emerging technology

Health Resources and Services Administration

telehealth grant programs/other federal initiatives

Improving or maintaining quality of care

Other: please list any other factors

Barriers to use

Concern regarding quality of care

 1

For the purposes of this report, we combined the tables for factors that encourage use or 

are barriers to use in one table. In the data collection instrument, the factors that 

encourage use or are barriers to use were separate for both telehealth and remote patient 

monitoring. 

Appendix II: Scope and Methodology for 

Identifying Factors Affecting the Use of 

Telehealth and Remote Patient Monitoring 
Appendix II: Scope and Methodology for 

Identifying Factors Affecting the Use of 

Telehealth and Remote Patient Monitoring

Page 42 GAO-17-365 Telehealth and Remote Patient Monitoring

Cost increase or inadequate payment

Coverage of services

Cultural factorsb

Infrastructure requirementsc

Pace of changing technology

Privacy and security concerns

Professional licensure issues

Provider/patient training requirements

Other: please list any other barriers 

Source: GAO analysis of background research documents and interviews with two groups with an interest in telehealth. | GAO-17-365

Note: Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.

a

We used the word “incentive” in the data collection instrument, which we are referring to as “factors 

that encourage” for the purpose of our report.

b

Cultural factors may include language and technological literacy, among others.

c

Infrastructure requirements may include access to broadband internet, imaging technology or 

peripherals, and wireless communications systems, among others.

To identify associations that might have an interest in telehealth and 

remote patient monitoring, we conducted background research, 

interviewed two groups with an interest in telehealth, and used knowledge 

from our previous engagements to judgmentally select associations 

based on their relevance and expertise. We chose associations that 

represented three health care perspectives—providers, patients, and 

payers. In addition, we chose medical specialty associations that 

represent common conditions for which telehealth or remote patient 

monitoring may be used, or could be beneficial, during the course of 

treatment, such as stroke, heart disease and congestive heart failure, and 

mental health. We included nine associations in our review: six 

associations that represent providers, two associations that represent 

patients, and one association representing payers.2

A representative of the payer association we spoke with told us that it did 

not have sufficient time to survey its members and could not complete our 

data collection instrument without doing so. Therefore, we reported 

 2

These associations are AARP, America’s Health Insurance Plans, American Heart 

Association/American Stroke Association, American Hospital Association, American 

Medical Association, American Telemedicine Association, National Association of Rural 

Health Clinics, National Patient Advocate Foundation, and Remote Cardiac Services 

Provider Group.
Appendix II: Scope and Methodology for 

Identifying Factors Affecting the Use of 

Telehealth and Remote Patient Monitoring

Page 43 GAO-17-365 Telehealth and Remote Patient Monitoring

separately the payer association’s views on factors that encourage the 

use of, or are barriers to, telehealth and remote patient monitoring. For 

the payer association, we interviewed officials to identify factors that 

encourage use or are barriers to the use of telehealth and remote patient 

monitoring in Medicare. We used professional judgment based on 

information obtained throughout the course of our engagement to match 

the payer association officials’ statements on factors that encourage use 

or are barriers to use with corresponding data collection instrument 

factors that encourage use or are barriers to use.

After identifying the associations, we administered the data collection 

instrument and requested that officials from each association rate each 

factor that encourages the use of telehealth and remote patient 

monitoring and each barrier to use. We requested that officials rate 

factors that encourage telehealth use, factors that encourage remote 

patient monitoring use, barriers to telehealth use, and barriers to remote 

patient monitoring use. For example, if an official identified a factor as 

encouraging the use of telehealth, we requested that the official rate the 

factor as not significant, somewhat significant, or very significant.

To identify the factors that encourage use or are barriers to use that were 

rated either most often or more often “very significant” or “somewhat 

significant” by the associations who completed our data collection 

instrument, we developed the following scoring system.

• Highest points (5) were assigned to an individual factor when an 

association rated it very significant for both telehealth and remote 

patient monitoring.

• Next highest points (3) were assigned to an individual factor when an 

association rated it very significant for either telehealth or remote 

patient monitoring and somewhat significant for either telehealth or 

remote patient monitoring.

• Lowest points (1) were assigned to an individual factor when an 

association rated it somewhat significant for both telehealth and 

remote patient monitoring.

No points were assigned for any other rating combinations.

We used this scoring system to separately calculate total points assigned 

to (1) each individual factor that encouraged use, and (2) each factor 

considered to be a barrier to use. Within either group (either among those 

that encouraged use or among those that were considered barriers to 

use), if any one or two factors had measurably greater scores than the 
Appendix II: Scope and Methodology for 

Identifying Factors Affecting the Use of 

Telehealth and Remote Patient Monitoring

Page 44 GAO-17-365 Telehealth and Remote Patient Monitoring

other factors, those factors were reported as rated most often very 

significant or somewhat significant. Additionally, we determined whether 

any other factor or several factors had obviously higher scores than the 

remaining factors that either encourage use or are a barrier to use, and 

we reported those factors as rated more often very significant or 

somewhat significant.

We also interviewed officials from each association using a structured 

question set to obtain examples of how these factors can encourage or 

create barriers to the use of telehealth and remote patient monitoring in 

Medicare. Finally, we obtained and reviewed any relevant documentation 

from these associations. The perspectives we obtained using the data 

collection instrument, from our document reviews, and during our 

interviews with association officials provided insights regarding officials’ 

views about the factors that encourage the use of telehealth and remote 

patient monitoring and the factors that are barriers to their use. These 

perspectives cannot be generalized to other associations or officials.
Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for Medicare 

& Medicaid Services, 2011-2016

Page 45 GAO-17-365 Telehealth and Remote Patient Monitoring

The Centers for Medicare & Medicaid Service (CMS)—an agency within 

the Department of Health and Human Services—has a process for adding 

or denying proposed services to the list of Medicare telehealth services.1

This process provides the public with an ongoing opportunity to submit 

requests for adding services. Under this process, CMS assigns requests 

to one of two categories:

1. services that are similar to professional consultations, office visits, and 

office psychiatry services that are currently on the list of telehealth 

services; and

2. services that are not similar to the current list of telehealth services. In 

reviewing these requests, CMS looks for evidence indicating that the 

use of a telecommunications system in furnishing the requested 

telehealth service produces clinical benefit for the patient.

The most common reason a proposed service was added for payment 

from calendar years 2011 through 2016 was similarity to a service already 

on the list of telehealth services. See table 5 for the Current Procedural 

Terminology and Healthcare Common Procedure Coding System codes 

that were approved by CMS, including the reason for adding the service, 

from calendar year 2011 through calendar year 2016.

 1

Medicare pays for a limited number of Part B services furnished by a physician or 

provider to an eligible beneficiary via a telecommunications system. Part B services 

include physician and outpatient hospital services. For eligible telehealth services, the use 

of a telecommunications system substitutes for an in-person encounter. 

Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for 

Medicare & Medicaid Services, 2011-2016
Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for Medicare 

& Medicaid Services, 2011-2016

Page 46 GAO-17-365 Telehealth and Remote Patient Monitoring

Table 5: Telehealth Service Codes Added by the Centers for Medicare & Medicaid Services (CMS), Calendar Years 2011 

through 2016

Calendar 

year 

Service 

code

Description of service CMS rationale for adding the service

2011 G0108 

G0109

Individual and group diabetes outpatient selfmanagement training servicesCMS initially denied this in 2009 because it might involve 

injection training. The agency approved it as sufficiently 

similar to G0270 medical nutrition therapy, but requires 1 

hour of in-person injection training.

G0420 

G0421

Individual and group kidney disease education Similar to another telehealth code, G0270 medical nutrition 

therapy.

96153 

96154 

97804

Group medical nutrition therapy services, and 

group Health Behavior Assessment and 

Intervention services 

Similar to other telehealth codes.

99231 

99232 

99233

Subsequent hospital care services Similar to follow-up inpatient consultation services. These 

services can only be furnished through telehealth once 

every 3 days.

99307 

99308 

99309 

99310

Subsequent nursing facility care services Similar to other telehealth codes. These services can only 

be furnished through telehealth once every 30 days.

2012 99406 

99407 

G0436 

G0437

Smoking and tobacco use cessation 

counseling, intermediate and intensive

Similar to individual kidney disease education reported by 

code G0420 and individual medical nutrition therapy 

services reported by G0270, 97802, and 97803. 

2013 G0396 

G0397

Alcohol and substance abuse assessment, 15 

to 30 minutes and greater than 30 minutes, 

respectively

Similar to an existing telehealth service: smoking cessation 

counseling 99406 and 99407.

G0442 

G0443 

G0444 

G0445 

G0446 

G0447

Screening for behavioral conditions: alcohol 

misuse and counseling, depression, sexually 

transmitted infections, cardiovascular disease, 

and obesity

Similar to existing behavioral intervention telehealth codes.

2014 99495 

99496

Transitional care management services with 

follow up communication, 14 days and 7 days 

after discharge, respectively

Similar to other telehealth services.

2015 G0438 

G0439

Annual wellness visit, initial and subsequent, 

respectively

Similar to existing behavioral intervention telehealth codes.

90845 

90846 

90847 

Psychoanalysis, family psychotherapy without 

patient, and family psychotherapy with patient, 

respectively

Similar to existing behavioral intervention telehealth codes.

99354 

99355

Prolonged service in the office or other 

outpatient setting requiring direct patient 

contact beyond the usual service, first hour and 

each additional 30 minutes, respectively

Similar to existing behavioral intervention telehealth codes.
Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for Medicare 

& Medicaid Services, 2011-2016

Page 47 GAO-17-365 Telehealth and Remote Patient Monitoring

Calendar 

year 

Service 

code

Description of service CMS rationale for adding the service

2016 90963 

90964 

90965 

90966

End-stage renal disease related services for 

home dialysis per full month; patients younger 

than ages 2, 2-11, 12-19, and 20+, respectively

Similar to existing psychiatric diagnostic procedures or 

office/outpatient visits codes.

99356 

99357

Prolonged service in the inpatient or 

observation settings, requiring unit/floor time 

beyond the usual service; first hour and 

additional 30 minutes, respectively

Similar to existing psychiatric diagnostic procedures or 

office/outpatient visits codes.

Source: GAO analysis of Federal Register Notices for Medicare Telehealth Services. | GAO-17-365

There are several reasons that CMS denied proposed services for its 

approved telehealth list for calendar years 2011 through 2016. These 

reasons are, for example, that

• the service was not like any other on the telehealth list, and the 

requester could not prove to CMS that the service is effective when 

furnished through telehealth;

• the service was furnished by a provider or in a location that is not 

allowed under Medicare;

• the service was not face-to-face when not provided via telehealth; and

• the service required face-to-face care because of patient acuity or 

another factor.

See table 6 for the Current Procedural Terminology and Healthcare 

Common Procedure Coding System codes that were denied by CMS and 

the reasons for denial, from calendar year 2011 through calendar year 

2016.
Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for Medicare 

& Medicaid Services, 2011-2016

Page 48 GAO-17-365 Telehealth and Remote Patient Monitoring

Table 6: Telehealth Service Codes Denied by the Centers for Medicare & Medicaid Services (CMS), Calendar Years 2011 

through 2016

Calendar 

year 

Service 

code

Description of service CMS rationale for denial

2011 96119 Neuropsychological testing Not similar to other telehealth services; no studies were provided on 

the efficacy of this service when provided through telehealth.

99221 

99222 

99223

Level 1, 2, and 3 initial hospital 

care, respectively

No current telehealth codes resemble initial hospital care like these, 

and CMS was not convinced by studies provided in support of the 

request.

99238 

99239

Hospital discharge management, 

less than 30 minutes and more, 

respectively

There are no services on the current list of telehealth services that 

resemble such preparation of a patient for discharge. CMS was not 

convinced by the studies provided in support of the request.

99304 

99305 

99306 

99315 

99316 

99318

Nursing facility care codes—initial, 

discharge, and annual assessment

Codes 99304, 99305, 99306, and 99318 are federally-mandated 

nursing facility visits that should be provided in person.

Codes 99315 and 99316 are not required to be furnished under 

Medicare, but if a provider chooses to provide these services, the 

services should be provided in person. No current telehealth codes 

resemble this preparation of a patient for discharge, and CMS did 

not have evidence that these services provided via telehealth are 

equivalent to in-person services.

No code 

provided

Home wound care The home is not an eligible telehealth originating site under 

Medicare.

No code 

provided

Speech language pathology 

services

Speech language pathologists are not eligible telehealth providers 

under Medicare.

2012 96040 Medical genetics and genetic 

counseling services

The services under this code would only be furnished by genetics 

counselors, who are not eligible telehealth providers.

99090 

99091

Analysis of clinical data stored in 

computers and collection and 

interpretation of physiologic data

As explained in a 2002 final rule, this code is part of pre- and postwork for a separate and unspecified evaluation and management 

code. These codes are not separately payable. CMS also denied 

these codes in 2015.

99291

99292

Critical care, evaluation and 

management of the critically ill or 

critically injured patient, first 30 to 

74 minutes and each additional 30 

minutes, respectively

Previously considered and denied adding these codes in 2009 and 

2010 because critical care services are not similar to any services on 

the current list of Medicare telehealth services and CMS believes 

patients requiring critical care services are more acutely ill than 

typical patients receiving telehealth services. Additionally, CMS did 

not have evidence that these services provided via telehealth are 

equivalent to in-person services.

99334 

99335 

99336 

99337

Domiciliary or rest home evaluation 

and management visit; 15 minute 

visit, 25 minute visit, 40 minute 

visit, and 60 minute visit 

respectively

A domiciliary or rest home is not an eligible telehealth originating site 

under Medicare.

99444 Online evaluation and management As indicated in 2008, 2012, 2014, and 2016, this is a noncovered 

service because it is non-face-to-face and the language of the 

descriptor indicates that the service could be for noncovered entities, 

like guardians.
Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for Medicare 

& Medicaid Services, 2011-2016

Page 49 GAO-17-365 Telehealth and Remote Patient Monitoring

Calendar 

year 

Service 

code

Description of service CMS rationale for denial

No code 

provided

Audiology services Audiologists are not authorized telehealth providers under Medicare.

2013 99408

99409

Alcohol and substance abuse 

screening, 15 to 30 minutes and 

greater than 30 minutes, 

respectively

These are noncovered services under the Physician Fee Schedule.a

As explained in 2008, Medicare only provides payment for certain 

screening services with an explicit benefit category. However, CMS 

created parallel codes—G0396 and G0397—and approved those for 

the telehealth list.

2014 98969 Online assessment and 

management service provided by a 

non-physician

These are noncovered services because it is non-face-to-face and 

the language of the descriptor indicates that the service could be for 

noncovered entities, like guardians.

99444 Online evaluation and management As indicated in comments for 2008, 2012, 2014, and 2016, this is a 

noncovered service because it is non-face-to-face and the language 

of the descriptor indicates that the service could be for noncovered 

entities, like guardians.

2015 57452 

57454

57460

Colposcopy of the cervix, 

colposcopy of the cervix with 

biopsy, and colposcopy of the 

cervix with loop electrode biopsy(s) 

of the cervix, respectively

These services are not similar to other services on the telehealth list 

and the requester did not submit evidence to support the clinical 

benefit of furnishing these services via telehealth.

90887 

99090

99091 

99358

99359

Interpretation of psychiatric 

examinations, analysis of clinical 

data stored in computers, collection 

and interpretation of physiologic 

data, prolonged evaluation and 

management, first hour and each 

additional 30 minutes, respectively

Medicare does not make a separate payment for these services.

92250 

93010 

93307 

93308 

93320 

93321 

93325

Fundus photography with 

interpretation and report, and five 

types of echocardiography services 

These services include a technical component and a professional 

component. By definition, the technical component portion of these 

services needs to be furnished in the same location as the patient 

and thus cannot be furnished via telehealth.

96103 

96120

Psychological testing, 

neuropsychological testing, 

respectively

These services involve testing by computer, can be furnished 

remotely without the patient being present, and are payable in the 

same way as other physicians’ services. These services are not 

Medicare telehealth services.

96101 

96102 

96118 

96119

Psychological testing per hour of 

physician time and technician time; 

neuropsychological testing per hour 

of physician time and technician 

time, respectively

These services are not similar to other services on the telehealth list, 

as they require close observation of how a patient responds. The 

requester did not submit evidence supporting the clinical benefit of 

furnishing these services via telehealth.

No code 

provided

Urgent dermatologic problems and 

wound care

Without a specified code, CMS cannot determine if this is an 

appropriate telehealth service.
Appendix III: Medicare Telehealth Services 

Added and Denied by the Centers for Medicare 

& Medicaid Services, 2011-2016

Page 50 GAO-17-365 Telehealth and Remote Patient Monitoring

Calendar 

year 

Service 

code

Description of service CMS rationale for denial

2016 99291

99292

Critical care, evaluation and 

management of the critically ill or 

critically injured patient, first 30 to 

74 minutes and each additional 30 

minutes, respectively

Previously considered and denied adding these codes in 2009, 

2010, and 2012 because critical care services are not similar to any 

services on the current list of Medicare telehealth services, and CMS 

believes patients requiring critical care services are more acutely ill 

than typical patients receiving telehealth services. Additionally, CMS 

did not have evidence that these services provided via telehealth are 

equivalent to in-person services. In 2016, CMS did not find that the 

submitted evidence demonstrates a clinical benefit to the patient.

99358 

99359

Prolonged evaluation and 

management service before or 

after direct patient care, first hour 

and each additional 30 minutes, 

respectively

As indicated in 2015, Medicare does not make a separate payment 

for these services.

99444 Online evaluation and management As indicated in 2008, 2012, 2014, and 2016, this is a noncovered 

service because it is inherently non-face-to-face and the language of 

the descriptor indicates that the service could be for noncovered 

entities, like guardians.

99490 Chronic care management services This service can be furnished without the beneficiary’s face-to-face 

presence and using any number of non-face-to-face means of 

communication.

99605 

99606 

99607

Medication therapy management 

services provided by a pharmacist, 

initial 15 minutes, new patient; 

initial 15 minutes, established 

patient; each additional 15 minutes, 

respectively

These are noncovered services under the Physician Fee Schedule.

No code 

provided

All evaluation and management 

services, telerehabilitation services; 

and palliative care, pain 

management and patient 

navigation services for cancer 

patients

The requests did not identify specific codes being requested, and 

two of the requests did not include evidence of any clinical benefit 

when the services are furnished via telehealth.

Source: GAO analysis of Federal Register Notices for Medicare Telehealth Services. | GAO-17-365

a

Medicare pays for physician and other health professional services based on a list of services and 

their payment rates, called the Physician Fee Schedule.
Appendix IV: Telehealth and Remote Patient 

Monitoring Reimbursement and Use in 

Selected State Medicaid Plans

Page 51 GAO-17-365 Telehealth and Remote Patient Monitoring

To better understand how telehealth and remote patient monitoring are 

used in Medicaid plans, we selected a sample of six states—Connecticut, 

Illinois, Kansas, Mississippi, Montana, and Oregon—to include in our 

review, and interviewed Medicaid officials from each of those states. We 

selected states that provide variation in geography, physical size, 

percentage of rural population, and other factors related to coverage and 

reimbursement for health care services.

The Centers for Medicare & Medicaid Services does not limit telehealth 

and remote patient monitoring use in Medicaid, thus reimbursement and 

use vary by state. The six states had a range of restrictions for the use of 

telehealth. For example, Illinois requires a medical professional be 

present with the patient receiving care at the originating site, while 

Oregon does not require anyone to be with the patient who is receiving 

care, at what is known as the originating site. More details on the use of 

telehealth and remote patient monitoring by selected state are included in 

table 7.

Table 7: Reimbursement and Use of Telehealth and Remote Patient Monitoring in Selected State Medicaid Programs

State characteristicsa Reimbursement of telehealth and remote patient 

monitoring

Use of telehealth and remote patient monitoring

Connecticut

Small

12 percent rural

Primarily fee-for-service

As described in state documentation, Connecticut 

passed a law effective July 1, 2016, for coverage 

under the Medicaid program for telehealth services 

that are (1) clinically appropriate to be provided by 

means of telehealth, (2) cost effective for the state, 

and (3) likely to expand access to medically 

necessary services for Medicaid recipients for whom 

accessing appropriate health care services poses an 

undue hardship. A Connecticut official told us that 

currently, Connecticut reimburses for provider-toprovider consults via secure electronic messaging, 

and does not reimburse for any other telehealth or 

remote patient monitoring services.

A Connecticut official told us that the state has 

considerable health resources and proximity to 

specialists, both in Connecticut and in neighboring 

states, and thus has less need for telehealth use. 

Illinois

Medium

12 percent rural

Primarily managed care

As described in state documentation, Illinois requires 

telehealth patients to be at an originating site with a 

physician or licensed health care professional or 

other clinician present. A physician’s office, 

podiatrist’s office, local health department, 

community mental health center, and outpatient 

hospitals are allowed as originating sites. Allowable 

providers of telehealth are hospitals, physicians, 

advanced practice nurses, podiatrists, federally 

qualified health centers, rural health clinics, and 

encounter rate clinics.b

Illinois officials told us telehealth is used frequently 

for psychiatric care. 

Appendix IV: Telehealth and Remote Patient 

Monitoring Reimbursement and Use in 

Selected State Medicaid Plans
Appendix IV: Telehealth and Remote Patient 

Monitoring Reimbursement and Use in 

Selected State Medicaid Plans

Page 52 GAO-17-365 Telehealth and Remote Patient Monitoring

State characteristicsa Reimbursement of telehealth and remote patient 

monitoring

Use of telehealth and remote patient monitoring

Kansas

Large

26 percent rural

Primarily managed care

As described in state documentation, Kansas does 

not limit reimbursement based on patient location and 

allows reimbursement for home-based telehealth. 

Kansas also does not limit the providers who can 

offer telehealth services. Kansas officials told us they 

reimburse for some remote patient monitoring 

services, such as monitoring of blood pressure, blood 

glucose, and weight.

Kansas officials told us that telehealth is a valuable 

tool, especially in supporting emergency room staff in 

hospitals without a level I or II trauma center nearby.c

The state has some experience with remote patient 

monitoring through a pilot project, which ran from 

September 2007 to June 2010 and, according to a 

Kansas report, reduced the rate of emergency 

department utilization.

Mississippi

Medium

51 percent rural

Primarily managed care

As described in state documentation, Mississippi 

reimburses for telehealth services that are medically 

necessary and would otherwise be covered in an inperson setting. Mississippi requires that telehealth be 

delivered in a live, interactive audiovisual format and 

does not reimburse for other types of services, such 

as telephone and email communication. Mississippi 

reimburses for telehealth services provided in specific 

originating sites. 

Mississippi officials told us they began reimbursing 

for telehealth and remote patient monitoring in 

January 2015. Officials told us they focus their use of 

telehealth on serving high-cost, high-use 

beneficiaries. 

Montana

Large

44 percent rural

Primarily fee-for-service

According to state officials, Montana does not restrict 

the use of telehealth. They started reimbursing for 

originating site fees in 2014, and have increased the 

number of sites where they provide an originating site 

reimbursement fee since 2014. Officials told us that 

they do not reimburse for remote patient monitoring.

Montana officials told us the state does not have any 

medical schools and has limited access to 

specialists. As such, telehealth services are important 

to providing patients with access to specialty care. 

Oregon

Large

19 percent rural

Primarily managed care

As described in state documentation, Oregon 

reimburses for medically appropriate covered 

telehealth services within the patient’s benefit 

package. In its definition of “telemedicine,” Oregon 

does not further specify restrictions on originating 

sites or provider types.

Oregon officials told us they see telehealth and 

remote patient monitoring as tools to be used by 

Oregon’s coordinated care organizations (CCO) 

when appropriate for delivering quality, value-based 

care.d

Source: U.S. Census Bureau data, state documents, and interviews with state officials. | GAO-17-365

Note: The term “originating site” refers to the location where the patient is located while receiving a 

telehealth service.

a

State size refers to the geographical size of the state and is based on U.S. Census 2010 data. Large 

states are from the largest third of states by size, medium states are from the middle third, and small 

states are from the smallest third. Rurality, the percentage of population living in a rural area, is based 

on U.S. Census 2010 data.

b

Encounter rate clinics are health care providers actively participating in the Illinois Department of 

Healthcare and Family Services’ Medical Assistance Program as an encounter rate clinic as of July 1, 

1988; or, a clinic operated by a county with a population of over three million.

c

According to the American Trauma Society, trauma center levels (I, II, III, IV, or V) refer to the kinds 

of resources available in a trauma center and the number of patients admitted yearly. The 

categorization of trauma center level varies from state to state (including distinctions of adult and 

pediatric centers). A level I facility is capable of providing total care for every aspect of injury, and a 

level II trauma center is able to initiate definitive care for all injured patients, while lower levels may 

not be able to offer as comprehensive of care.

d

As described in state documentation, Oregon defines a CCO as a network of all types of health care 

providers (physical health care, addiction and mental health care, and sometimes dental care 

providers) who have agreed to work together in their local communities to serve people who receive 

health care coverage under Oregon’s Medicaid plan.
Appendix V: Selected Associations’ Rating of 

the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring

Page 53 GAO-17-365 Telehealth and Remote Patient Monitoring

Through an administered data collection instrument, officials from six 

associations representing providers and two associations representing 

patients identified, and rated the significance of, factors that encourage—

and barriers that limit—the use of telehealth and remote patient 

monitoring in Medicare.1 Officials were asked to respond from the 

perspective of their association, specifically from a provider or patient 

perspective, depending on the association.2

Figures 4 and 5 show how provider and patient associations rated the 

significance of factors that encourage the use of telehealth and remote 

patient monitoring in Medicare. Figures 6 and 7 show how provider and 

patient associations rated the significance of barriers to the use of 

telehealth and remote patient monitoring in Medicare.

 1

For the purposes of this report, telehealth refers to clinical services that are provided 

remotely via telecommunications technologies, while remote patient monitoring is a 

technology to enable monitoring of patients outside of conventional clinical settings, such 

as in the home.

2

A representative of the payer association we spoke with told us that it did not have 

sufficient time to survey its members and could not complete our data collection 

instrument without doing so. Therefore, we reported separately the payer association’s 

views on factors that encourage the use of or are barriers to telehealth and remote patient 

monitoring.

Appendix V: Selected Associations’ Rating of 

the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring
Appendix V: Selected Associations’ Rating of 

the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring

Page 54 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 4: Significance of Factors That Encourage the Use of Telehealth in Medicare, According to Selected Provider and 

Patient Associations
Appendix V: Selected Associations’ Rating of 

the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring

Page 55 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 5: Significance of Factors That Encourage the Use of Remote Patient Monitoring in Medicare, According to Selected 

Provider and Patient Associations

Note: Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.
Appendix V: Selected Associations’ Rating of 

the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring

Page 56 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 6: Significance of Barriers to the Use of Telehealth in Medicare, According to Selected Provider and Patient 

Associations

a

Cultural factors may include language and technological literacy, among others.

b

Infrastructure requirements may include access to broadband internet, imaging technology or 

peripherals, and wireless communications systems, among others.
Appendix V: Selected Associations’ Rating of 

the Significance of Factors that Affect 

Telehealth and Remote Patient Monitoring

Page 57 GAO-17-365 Telehealth and Remote Patient Monitoring

Figure 7: Significance of Barriers to the Use of Remote Patient Monitoring in Medicare, According to Selected Provider and 

Patient Associations

Note: Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.

a

Cultural factors may include language and technological literacy, among others.

b

Infrastructure requirements may include access to broadband internet, imaging technology or 

peripherals, and wireless communications systems, among others.
Appendix VI: Medicare Valuation of Remote 

Patient Monitoring

Page 58 GAO-17-365 Telehealth and Remote Patient Monitoring

Remote patient monitoring refers to a coordinated system that uses one 

or more home-based or mobile monitoring devices that transmit vital sign 

data or information on activities of daily living that are subsequently 

reviewed by a health care professional. This process can enable 

providers to closely track a patient’s condition and provide earlier 

intervention to potential problems.1 According to a report by the Agency 

for Healthcare Research and Quality, remote patient monitoring has been 

shown to produce positive outcomes, such as reduced hospitalization, 

when used as a part of care management for chronic conditions such as 

diabetes and congestive heart failure.

A June 2016 report by the Medicare Payment Advisory Commission 

(MedPAC) found that Medicare covers some services through its 

Physician Fee Schedule that involve remote monitoring of a patient.2 For 

example, MedPAC’s analysis of 2014 Medicare data found that the 

agency spent $119 million on remote cardiac monitoring services for

265,000 beneficiaries. While remote patient monitoring is used in 

Medicare, there are concerns about how to establish accurate valuations 

for some of these services’ Medicare payment rates in the Physician Fee 

Schedule. To identify these concerns, we collected documentation from 

and interviewed associations representing provider, patient, and payer 

 1

Monitoring programs can collect a wide range of health data from the point of care, such 

as weight, blood pressure, blood glucose, blood oxygen levels, and heart rate.

2

Medicare Payment Advisory Commission, Report to the Congress: Medicare and the 

Health Care Delivery System, (Washington, D.C.: June 15, 2016). MedPAC noted that 

Medicare also covers many services under the Physician Fee Schedule that involve a 

provider’s remote interpretation of a diagnostic test. For example, a hospital can perform 

an imaging study on a patient and transmit the images electronically to a radiologist to 

interpret the images in another location. Medicare pays for physician and other health 

professional services based on a list of services and their payment rates, called the 

Physician Fee Schedule.

Appendix VI: Medicare Valuation of Remote 

Patient Monitoring
Appendix VI: Medicare Valuation of Remote 

Patient Monitoring

Page 59 GAO-17-365 Telehealth and Remote Patient Monitoring

associations.3 We also reviewed documentation and conducted 

interviews with Centers for Medicare & Medicaid Services (CMS) officials.

CMS—the agency within the Department of Health and Human Services 

that administers the Medicare program—values remote patient monitoring 

services in the same way it values other physician services—by setting 

payment rates primarily as a result of underlying relative values that CMS

assigns to each service.4 These relative values largely reflect estimates of 

the level of physician work and the amount of practice expenses needed 

to provide one service relative to other services.5 Physician work relative 

values are based on the estimate of two main inputs: (1) the time the 

physician needs to perform the service (including pre- and post-service 

activities, or work performed before and after the service), and (2) the 

intensity of the service (including the physician’s mental effort and 

judgment, technical skill and physical effort, and psychological stress). 

Practice expense relative values are based primarily on estimates of (1) 

direct practice expense inputs, which reflect the clinical labor, medical 

equipment, and disposable supplies needed to provide a specific service 

as well as the amount of time for which labor is required and equipment is 

used, and (2) indirect practice expenses, which generally reflect overhead 

expenses not associated with a specific service.6

 3

In conducting our work to describe factors identified as encouraging the use of or creating 

barriers to remote patient monitoring in Medicare, we collected documentation from and 

interviewed representatives of associations who represented providers, patients, and 

payers. To identify these associations, we reviewed relevant documents and literature and 

conducted interviews to identify general associations, as well as specialty associations 

that represent common conditions for which telehealth or remote patient monitoring may 

be used, or could be beneficial, during the course of treatment, such as stroke, congestive 

heart failure, and mental health. We included 10 associations in our review: 7 associations 

that represent providers, 2 associations that represent patients, and 1 association 

representing payers. Not all associations commented on concerns regarding the Medicare 

valuation of remote patient monitoring. 

4

CMS generates initial relative values for new services and may revise relative values for 

existing services to maintain their accuracy. The agency generally reviews valuation for 

several hundred service codes per year, while rates are re-calibrated annually to maintain 

relativity among the services. CMS reviews the relative values of all physicians’ services 

at least every 5 years. 

5

A third resource, malpractice relative values, accounts for the cost of malpractice 

insurance premiums of the specialties that perform the service.

6

For more information about CMS’s process for establishing relative values, see GAO, 

Medicare Physician Payment Rates: Better Data and Greater Transparency Could 

Improve Accuracy, GAO-15-434 (Washington, D.C.: May 21, 2015).
Appendix VI: Medicare Valuation of Remote 

Patient Monitoring

Page 60 GAO-17-365 Telehealth and Remote Patient Monitoring

Several characteristics of remote patient monitoring services have been 

identified by some of the selected associations we interviewed as raising 

challenges to valuation within CMS’s methodology, such as the services’ 

personnel and technology, and the operating hours and location of where 

certain remote patient monitoring services are delivered. Additionally, 

officials from one provider association noted that some parts of CMS’s 

process for developing Medicare valuation may not consider input from 

stakeholders most knowledgeable about the technical components of the 

services.

Personnel. Officials from an association representing certain providers of 

remote patient monitoring services told us that Independent Diagnostic 

Testing Facilities frequently perform remote patient monitoring services 

that include patient diagnostic testing, but some personnel costs may not 

be recognized in the Medicare valuation methodology because these 

personnel are not considered clinical staff.7 For example, personnel 

involved in remote cardiac monitoring at Independent Diagnostic Testing 

Facilities include non-clinical administrative staff who the association 

officials noted are not adequately accounted for in the CMS methodology.

Technology. Officials from this same association also noted that the 

costs of technology associated with remote patient monitoring may not be 

fully captured by CMS’s valuation methodology. For example, while 

wearable remote devices only monitor one patient at a time, wireless 

communication systems—with their hardware and software costs—that 

can be used to remotely monitor multiple patients at a time are not 

attributed to an individual patient when considering the direct practice 

expense inputs.8 Therefore, this type of equipment is classified within the 

indirect cost category (with overhead costs), resulting in lower payment 

 7

An Independent Diagnostic Testing Facility is a diagnostic testing facility that is 

independent of a physician office or hospital. Its purpose is to furnish diagnostic tests and 

not to directly use test results to treat a patient.

8

CMS officials explained that for costs that are not attributable to individual patients, like a 

centralized monitoring system, the established practice expense methodology considers 

these costs, like others not attributable to individual services or patients, to be indirect 

costs. According to officials, they are accounted for through the allocation of indirect 

practice expense relative value units that would be assigned to the code billed for the 

monitoring. In contrast, the equipment costs of the monitor worn by an individual patient 

would be a direct practice expense cost assigned to a particular service code. This direct 

practice expense cost would serve as an allocator for indirect practice expense relative 

value units to be assigned to the code (these might represent the costs associated with 

centralized monitoring equipment).
Appendix VI: Medicare Valuation of Remote 

Patient Monitoring

Page 61 GAO-17-365 Telehealth and Remote Patient Monitoring

rates than if these costs were considered direct costs, according to 

association officials. Additionally, other unique costs for remote patient 

monitoring related to technology include such things as the cost of 

delivering the monitoring device to the patient and the cost of the patient 

returning the device after the monitoring period has ended.

In addition, technology used to provide remote patient monitoring services 

can vary among service providers and is evolving, contributing to 

difficulties in developing valuation for the services. Officials with a payer 

association said there is variation among the type of devices the patient 

or provider must possess or that must be installed in the patient’s home to 

carry out remote patient monitoring, such as motion sensors to determine 

if a patient has fallen or the components that transmit biometric 

information such as blood pressure or weight back to the monitoring site. 

Officials with a second provider association noted that remote patient 

monitoring technology continues to evolve, and for such newly-developed 

technology there is not a consensus in how to use and charge for the 

multiplicity of delivery models, including the range of services and 

procedures.

Hours of operation and location. Some remote patient monitoring may 

require a monitoring facility to operate 24 hours a day, 7 days per week. 

An association representing certain providers of remote patient 

monitoring services noted that Medicare’s valuation methodology, which 

CMS officials stated was designed for and primarily applies to services 

furnished in standard physician offices during business hours, may not 

fully incorporate costs associated with maintaining operations outside of 

standard business hours and in non-physician office settings, such as at 

Independent Diagnostic Testing Facilities or other types of remote 

monitoring centers.

Knowledgeable stakeholders. CMS works with a committee established 

by the American Medical Association (AMA)—the AMA/Specialty Society 

Relative Value Scale Update Committee (RUC)—three times a year 

annually to review a subset of physicians’ services, identified in part by 

CMS and in part by the RUC, to develop recommendations to CMS on 

the resources needed to provide those specific services. RUC members 

generally represent physician specialty societies, such as those for 
Appendix VI: Medicare Valuation of Remote 

Patient Monitoring

Page 62 GAO-17-365 Telehealth and Remote Patient Monitoring

cardiology, family medicine, and internal medicine.9 However, for services 

such as the cardiac monitoring services that are widely provided by 

Independent Diagnostic Testing Facilities, representatives from 

Independent Diagnostic Testing Facilities do not serve on the RUC and 

do not officially participate in the RUC process as advisors regarding 

these services, according to officials with the association representing 

certain providers of remote patient monitoring services.

CMS response to cited concerns. CMS officials agreed that the 

payment rates that result from the application of the current Medicare 

methodology may reflect relative resources for services furnished in the 

typical physician office rather than other locations. Officials said that they 

use CMS’s annual rulemaking process for setting payment rates for the 

Physician Fee Schedule to address services, such as remote patient 

monitoring, that vary from the usual service delivery model.10 CMS 

officials said this process affords members of the public an opportunity to 

recommend codes to be considered for revaluation if they believe the 

services are inappropriately valued. Some examples CMS officials cited 

include the following:

• In revisions to the Physician Fee Schedule for calendar year 2016, 

CMS increased the input price for patient worn telemetry system 

equipment, which is a factor in establishing the payment rate for 

cardiovascular telemetry transmitted to a remote attended 

surveillance center for up to 30 days. In response to a request 

received in a public comment period during the annual Physician Fee 

Schedule rulemaking, CMS increased the price from $21,575 to 

$23,537 to account for the unique properties of the equipment, 

including its use 24 hours per day and 7 days per week for an 

individual patient over several weeks and its use primarily outside of a 

health care setting.

• CMS has developed codes within the Physician Fee Schedule that 

describe the non-face-to-face care management services that include 

 9

The RUC members are supported by physician representatives who are responsible for 

coordinating with their respective specialty societies to develop relative value 

recommendations to present to the RUC.

10Each year CMS publishes proposed and then final rules setting out revisions to payment 

policies under the Physician Fee Schedule, which include relative values for existing 

services and for new services as well as opportunities both for public comment on these 

proposals and for requests from interested parties regarding payment rates for Medicare 

services.
Appendix VI: Medicare Valuation of Remote 

Patient Monitoring

Page 63 GAO-17-365 Telehealth and Remote Patient Monitoring

interactions furnished through communication technology. These nonface-to-face services are associated with managing the particular 

needs of patients and are furnished over the course of a calendar 

month.
Appendix VII: Examples of Telehealth and 

Remote Patient Monitoring in Medicare Models 

and Demonstrations

Page 64 GAO-17-365 Telehealth and Remote Patient Monitoring

The Patient Protection and Affordable Care Act created the Center for 

Medicare & Medicaid Innovation (Innovation Center) within the Centers 

for Medicare & Medicaid Services to test innovative payment and service 

delivery models to reduce Medicare, Medicaid, and state Children’s 

Health Insurance Program expenditures while preserving or enhancing 

the quality of care.1 The Innovation Center also supports Medicare 

demonstration projects, which study the likely impact of new methods of 

service delivery, coverage of new types of services, and new payment 

approaches on beneficiaries, providers, health plans, states, and the

Medicare trust funds. The Innovation Center has organized the models 

and demonstrations into seven categories. Table 8 shows the seven 

categories and for each provides a description and an example of how a 

model or demonstration within that category may use telehealth or remote 

patient monitoring.2

Table 8: Centers for Medicare & Medicaid Services’ Innovation Center Categories and Examples of Potential Telehealth and 

Remote Patient Monitoring Use in Models or Demonstrations

Innovation Center 

category

Category description Example of a model or demonstration 

that can use telehealth or remote 

patient monitoring 

Accountable care Accountable Care Organizations (ACO) and similar care models 

are designed to incentivize health care providers to become 

accountable for a patient population and to invest in infrastructure 

and redesigned care processes that provide for coordinated care, 

high quality, and efficient service delivery.

Next Generation ACO: This model 

allows beneficiaries to receive telehealth 

services at home and in urban areas. 

Episode-based 

payment initiatives

Under these models, health care providers are held accountable for 

the cost and quality of care that beneficiaries receive during an 

episode of care, which usually begins with a triggering health care 

event—such as a hospitalization or chemotherapy administration—

and extends for a limited period of time thereafter.

Bundled Payments for Care 

Improvement models 2 and 3: These 

models remove geographic limitations on 

the use of telehealth services. 

Primary care 

transformation

Advanced primary care practices—also called medical homes—

utilize a team-based approach, while emphasizing prevention, 

health information technology, care coordination, and shared 

decision making among patients and their providers.

Independence At Home Demonstration: 

This demonstration requires practices to 

have the ability to use remote patient 

monitoring and mobile diagnostic 

technology with their patients.

 1

Pub. L. No. 111-148, §§ 3021, 10306, 124 Stat. 119, 389, 939 (codified at 42 U.S.C. § 

1315a).

2

For the purposes of this report, telehealth is defined as clinical services that are provided 

remotely via telecommunications technologies, while remote patient monitoring is a 

technology to enable monitoring of patients outside of conventional clinical settings, such 

as in the home.

Appendix VII: Examples of Telehealth and 

Remote Patient Monitoring in Medicare 

Models and Demonstrations
Appendix VII: Examples of Telehealth and 

Remote Patient Monitoring in Medicare Models 

and Demonstrations

Page 65 GAO-17-365 Telehealth and Remote Patient Monitoring

Initiatives focused on 

the Medicaid and 

CHIP populations

Medicaid and the state Children’s Health Insurance Program 

(CHIP) are administered by the states but are jointly funded by the 

federal government and states. Initiatives in this category are 

administered by the participating states.

Medicaid Incentives for the Prevention of 

Chronic Disease: This model included 

grantees that use telehealth to reach 

participants dispersed through a large 

region. 

Initiatives focused on 

the MedicareMedicaid enrollees

Individuals enrolled in both Medicare and Medicaid (the “dual 

eligibles”) account for a disproportionate share of the programs’ 

expenditures. According to the Center for Medicare & Medicaid 

Innovation, a fully integrated, person-centered system of care that 

ensures that all their needs are met could better serve this 

population in a high quality, cost-effective manner. 

The Initiative to Reduce Avoidable 

Hospitalizations among Nursing Facility 

Residents: This model includes a 

participant that plans to use telehealth to 

provide after-hours telehealth services 

when needed. 

Initiatives to 

accelerate the 

development and 

testing of new 

payment and service 

delivery models

Many innovations necessary to improve the health care system are 

expected to come from local communities and health care leaders 

from across the country. By partnering with these local and regional 

stakeholders, the Centers for Medicare & Medicaid Services 

intends to help accelerate the testing of new models.

The Frontier Community Health 

Integration Project Demonstration: This 

demonstration includes testing the use of 

telehealth in critical access hospitals.

Initiatives to speed the 

adoption of best 

practices

The Center for Medicare & Medicaid Innovation is partnering with a 

broad range of health care providers, federal agencies, 

professional societies, and other experts and stakeholders to test 

new models for disseminating evidence-based best practices and 

significantly increasing the speed of adoption.

The Million Hearts Initiative: This 

initiative includes information for 

providers about how they may be able to 

be paid for at-home blood pressure 

monitoring devices, and additional 

information on potential remote patient 

monitoring use.

Source: GAO analysis of Centers for Medicare & Medicaid Services documentation. | GAO 17-365

Note: Remote patient monitoring is a technology to enable monitoring of patients outside of 

conventional clinical settings, such as in the home.
Appendix VIII: GAO Contact and Staff 

Acknowledgments

Page 66 GAO-17-365 Telehealth and Remote Patient Monitoring

Carolyn L. Yocom, (202) 512-7114, yocomc@gao.gov

In addition to the contact named above, Karen Doran, Assistant Director; 

Sarah Resavy, Analyst-in-Charge; Luke Baron; Muriel Brown; Krister 

Friday; Monica Perez-Nelson; and Helen Sauer made key contributions to 

this report.

Appendix VIII: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100769)
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