What an audio-only visit counts as

Where the definition lives matters

Washington defines audio-only telemedicine in more than one chapter, and the most detailed version sits in an insurance section about what a health carrier must reimburse.

That location bounds what the definitions do. Several of them are introduced with the phrase "for purposes of this section only", and the section as a whole governs coverage and payment rather than how any clinician must practise.

A parallel set of definitions appears in the hospital licensing chapter, which is scoped to that chapter in the same way. The wording of the two is closely aligned, which is useful, but neither is a free-standing practice standard.

The reimbursement section defines telemedicine as the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment, and states that for purposes of that section telemedicine includes audio-only telemedicine but does not include facsimile or email.

Audio-only telemedicine is defined as the delivery of health care services through the use of audio-only technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. Real-time is part of the definition, which is what separates it from the asynchronous category the same section defines.

What the category excludes

The exclusions are as informative as the inclusions, and there are two of them in the audio-only definition.

Audio-only telemedicine does not include the use of facsimile or email. Text-based exchange is outside the definition entirely, in both the insurance section and the hospital chapter.

It also does not include the delivery of health care services that are customarily delivered by audio-only technology and customarily not billed as separate services by the provider, and the statute gives its own example: the sharing of laboratory results.

That second exclusion is the practical one. A telephone call to convey a result is not converted into a billable audio-only telemedicine encounter by the fact that it happened over the telephone.

The section defines the asynchronous category separately. Store and forward technology means the use of an asynchronous transmission of a covered person's medical information from an originating site to the health care provider at a distant site which results in medical diagnosis and management of the covered person, and it does not include the use of audio-only telephone, facsimile, or email.

The prior relationship condition

The condition that distinguishes audio-only from the rest of the section is a requirement that the patient and provider already know each other, and the statute defines what that means.

For audio-only telemedicine, reimbursement under the section is conditioned on the covered person having an established relationship with the provider.

Established relationship means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services, and one of two further things.

The first route is a prior appointment. The covered person has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider giving the audio-only care or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under the named chapters.

The second route is a referral. The covered person was referred to the audio-only provider by another provider who has had, within the past three years, at least one in-person appointment or one real-time audio and video appointment with them, and who has provided relevant medical information to the audio-only provider.

Consent before the bill

The section attaches a separate duty to billing, and it runs ahead of the service rather than after it.

If a provider intends to bill a patient or the patient's health plan for an audio-only telemedicine service, the provider must obtain patient consent for the billing in advance of the service being delivered.

That is consent to being billed, not consent to treatment, and the timing requirement is explicit: in advance of the service being delivered.

Enforcement runs through the insurance regulator into the health professions system. If the commissioner has cause to believe a provider has engaged in a pattern of unresolved violations of that subsection, the commissioner may submit information to the appropriate disciplining authority for action, and may first give the provider an opportunity to cure the alleged violations or explain why the actions did not violate the subsection.

The receiving end of that referral is written into the professional discipline statute independently. Washington's enumerated unprofessional conduct list includes a pattern of violations of the billing-consent subsection among several named provisions, so the payment rule and the licensure standard are joined at that point.

Where the patient is, and what may be charged for it

The section defines the geography of a telemedicine encounter, and the list of originating sites includes one entry that changes the shape of the rest.

Originating site means the physical location of a patient receiving health care services through telemedicine, and distant site means the site at which a physician or other licensed provider delivering a professional service is physically located at the time the service is provided.

The enumerated originating sites for a service subject to the reimbursement requirement include a hospital, a rural health clinic, a federally qualified health centre, a physician's or other health care provider's office, a licensed or certified behavioural health agency, a skilled nursing facility, a renal dialysis centre other than an independent one, and the home or any location determined by the individual receiving the service.

Facility fees turn on that list. Any originating site other than the home or a location the individual determines may charge a facility fee for infrastructure and preparation of the patient, subject to a negotiated agreement with the carrier, while a distant site, a hospital that is an originating site for audio-only telemedicine, and any site not on the list may not charge one.

Two further limits keep the section in its lane. A carrier may not distinguish between rural and urban originating sites in providing the coverage required, and a carrier may subject a telemedicine or store-and-forward service to all the terms and conditions of the plan, including utilisation review, prior authorisation, deductible, copayment or coinsurance requirements applicable to a comparable in-person service.

The section also sets a payment-parity rule with a carve-out that shapes who it applies to. A carrier must reimburse a provider for a health care service provided through telemedicine the same amount of compensation it would pay if the service had been provided in person, except that hospitals, hospital systems, telemedicine companies, and provider groups consisting of eleven or more providers may elect to negotiate a different amount. For counting purposes, the number of providers in a group refers to all providers within the group regardless of a provider's location.

What the section does not require is listed as well, and it is the outer edge of the whole scheme. It does not require a carrier to reimburse an originating site for professional fees, to reimburse a provider for a health care service that is not a covered benefit under the plan, or to reimburse an originating site or health care provider that is not a contracted provider under the plan.

Sources

Each document below is named as it names itself, with the date printed on that document rather than the day it was read.

1. Revised Code of Washington 48.43.735, reimbursement for telemedicine and store and forward technology, including the audio-only definitions, established relationship and billing consent — Washington State Legislature, 2024
2. Revised Code of Washington 70.41.020, hospital licensing chapter definitions, including telemedicine and audio-only telemedicine — Washington State Legislature, 2025
3. Revised Code of Washington 18.130.180, Unprofessional conduct, including a pattern of violations of the audio-only billing consent subsection — Washington State Legislature, 2025