eConsults are a key clinical innovation that can assist in addressing inequities in access to specialty care. eConsults are designed for use in place of a referral or a curbside consult and in lieu of an in-person evaluation by the specialist. For referral questions primarily assessed using clinical data, eConsults have several potential advantages over a standard referral. In appropriate cases, the patient receives timely access to specialist expertise, avoids the costs associated with an office visit (e.g., travel to the health center, an insurance co-pay, a missed half day of work), and maintains relationship continuity with the primary care physician. For patients who face traditional barriers to accessing care, such as transportation or costs, eConsults are a helpful resource for obtaining timely specialty input.
Through the CORE® Network, health systems are sharing their approaches to understanding health care equity within their programs and creating resources to support assessment and measurement. In 2023, the CORE Health Care Equity Workgroup published a resource, Advancing Health Care Equity Through eConsults, detailing how eConsults can help to enable health care equity as well as tools and metrics for assessing equity within eConsult programs. For more information, the executive summary (PDF) of this report is available.
eConsult Payment Policy
There have been several important policy updates related to eConsults and reimbursement since 2019.
Policy Updates
- The CMS announced its new Making Care Primary model, which is aimed at improving primary care-specialty care coordination and value with eConsults as a key feature of participation for advanced track participants (June 2023).
- The CMS issued a state health official letter allowing and encouraging the coverage of interprofessional consults (PDF) under the Medicaid and CHIP programs, reversing a previous policy (January 2023).
- The CMMI highlighted Project CORE eConsults and enhanced referrals as a strategy for specialty integration in its blog post, “The CMS Innovation Center’s Strategy to Support Person-centered, Value-based Specialty Care” (November 2022).
- Medicare approved payment for two new CPT codes (99451, 99452) that reimburse both the treating provider (typically, a primary care provider) and consulting provider for interprofessional consults. Each code is valued at 0.7 wRVU each.
AAMC Comments on eConsult Policy Recommendations
The following AAMC comment letters include recommendations for how federal agencies can continue to support scale of eConsults and optimize existing policy to further promote scale and sustainability of eConsults nationally:
- The AAMC submitted comments (PDF) to the Centers for Medicare & Medicaid Services on Sept. 11, 2023, in response to the calendar year 2024 Physician Fee Schedule and Quality Payment Program proposed rule. In the comments, the AAMC highlighted some of the barriers to uptake and sustainability of e-consults with the current CPT codes as well as the benefits programs have seen with e-consults including for behavioral health (see pages 32-35).
- In June 2023, the AAMC submitted a comment letter (PDF) to the Office of the National Coordinator for Health Information Technology in response to its notice of proposed rulemaking, “Health Data, Technology, and Interoperability: Certification Program Updates, Algorithm Transparency, and Information Sharing.” Among comments provided, the letter highlighted broader challenges to interoperability beyond necessary data standardization, including insights from Project CORE programs around eConsults and interoperability.