In March 2020, the COVID-19 pandemic became a catalyst for a massive transformation of the U.S. health care system. As medical offices shut down and patients feared leaving their homes, the environment was ripe for virtual care to grow. Virtual care includes video visits (ie, video conferencing with patients), asynchronous visits such as portal messaging, and tools to monitor patients at home. The growth of virtual care was made possible because the pandemic was deemed a national public health emergency (PHE). The PHE enabled substantial legal and regulatory changes which opened the doors for the growth of virtual care with minimal restrictions. While many states have since allowed their state-level emergency orders to expire, the national PHE has not expired yet. Therefore, many virtual care flexibilities remain in place.

There is no doubt that virtual care is here to stay after the PHE. In fact, the U.S. House of Representatives recently passed the Advancing Telehealth Beyond COVID-19 Act of 2021 with overwhelming bipartisan support (416-12). At the time of this writing, the bill has not passed the Senate, but the White House has already expressed support for its passage. If made into law, it would extend the majority of key virtual care flexibilities (eg, coverage for audio-only telehealth, elimination of geographic restrictions) that prevailed during the PHE until December 31, 2024.

While most of us who follow virtual care policy closely are confident that Medicare, Medicaid, and other payers will permanently recognize and reimburse virtual care, there are still some key unknowns about the final shape and form of virtual care after the PHE.

Will audio-only telehealth visits be reimbursed after the PHE? During the PHE, Medicare, Medicaid, and most commercial payers allowed audio-only telehealth. While there seems to be substantial bipartisan support to continue Medicare coverage for audio-only telehealth, the coverage is not guaranteed and requires passage of a bill such as the Advancing Telehealth Beyond COVID-19 Act of 2021. While state Medicaid and commercial payers tend to follow suit with Medicare coverage rules, it is not always the case. Furthermore, even if audio-only telehealth is covered, it is unclear whether these visits will be reimbursed at the same payment rate as video visits. While the future of audio-only telehealth coverage is uncertain, the evidence supporting the value of its coverage is abundant. Many studies have shown that eliminating coverage for audio-only telehealth can lead to disparities in virtual care.^1,2 Hence, it is difficult to argue against coverage for audio-only telehealth if the goal of virtual care is to improve the health of all populations.

Will I be able to practice virtual care across state lines? During the PHE, all 50 states and the District of Columbia used emergency orders to allow clinicians to practice virtual care across state lines. Unfortunately, as of August 3, 2022, 39 states have allowed the emergency declarations to expire.³ Currently, only 14 states allow out-of-state clinicians to perform virtual care across state lines. While the majority of U.S. health care is performed within state lines, care from out-of-state clinicians is essential for residents in some states.^4,5 Unfortunately, the issue of allowing clinicians to practice across state lines will not be easily resolved after the PHE. Medical licensure is governed at the state level. Even if insurers allow their beneficiaries to receive out-of-state care, medical licensure rules still apply. Clinicians can effectively pursue multiple out-of-state medical licenses through the Interstate Medical Licensure Compact; however, a national medical license or other universal solution is unlikely. In most cases, urologists and advanced practice providers who practice telehealth across state lines will need to ensure not only that they meet the licensure laws of the state where the patient is located, but also that the patient’s insurance, and the practice’s malpractice insurance, will cover it.

Will video visits be reimbursed at the same rate as in-person visits? At this time, there is no obvious sign that Medicare will reimburse video visits at a lower rate than in-person visits. But without payment parity laws at the state level, commercial insurers may start to do so. While there are multiple reasons why payment rates between in-person visits and video visits should remain equal,⁶ the question of whether or not payment rates will drop after the PHE is unknown at this time.

In summary, this author has no doubt that virtual care will continue to be a critical means of accessing urological care after the PHE is over. That said, there will almost certainly be more restrictions on how it can be delivered. For the urology community, it will be important to stay up to date on evolving reimbursement structures and regulatory compliance to ensure that our patients are receiving high-quality care without the risk of a surprise bill. The AUA’s Telehealth Task force and other policy advocates are working hard to ensure that the transition to a post-PHE era of virtual care is seamless. We strongly believe that virtual care has the potential to make urological care more efficient and accessible.