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
- In June 2023, the CMS announced its 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.
- In January 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.
- 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).
- In 2019, 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.