For many Medicare patients, telehealth meant a phone call
CMS’s April 30, 2020, rule paid audio-only visits at levels comparable to office visits. For many older, rural and low-income patients the phone was the only telehealth that worked, so it needed its own workflow and controls.
Looking Back revisits one week at a time, from January 2020 to today, and asks what it meant for the banks, health systems and public agencies we serve. The series was written in 2026, with the benefit of hindsight, and each article says which week it looks back on.
The week
On April 30, 2020, the Centers for Medicare & Medicaid Services issued a second interim final rule on COVID-19 flexibilities. Among other changes, it raised Medicare payment for telephone evaluation and management visits to levels equivalent to similar office and outpatient visits, retroactive to March 1, 2020. It also broadened the range of services that could be furnished by audio-only telephone. CMS said it would add services to the Medicare telehealth list on a quicker, subregulatory basis during the emergency. The change responded to reports from providers that many Medicare patients could not use video visits because they lacked devices, broadband or familiarity with the technology.
Telehealth in 2020 is usually remembered as video. For a large share of Medicare patients, it was a phone call. The April 30 rule recognized that by paying for audio-only visits at levels comparable to in-person care. Health systems then had to treat the telephone as a channel in its own right. That raised three design questions for patient experience, digital and operations leaders: who the phone channel served, how phone visits fitted clinical and administrative workflows, and which controls a low-friction channel required.
Who the phone channel served
Video visits assume a smartphone or computer with a camera, enough broadband, software that works and the confidence to use it. Many older adults, rural residents and low-income patients lacked one or more of those. Patients with limited English proficiency faced an extra barrier when interpreters could not easily join a video session. Some patients with disabilities found video harder rather than easier. For these groups, the telephone was the only version of telehealth that worked.
That made audio-only an equity decision. A health system offering only video would, in effect, have offered telehealth mainly to patients who were already easier to reach. Leaders needed data on which patients used which channel, broken down by age, language, payer and geography. Many organizations could not produce it, because visit modality was recorded inconsistently or only in free text. Adding a required modality field to every virtual visit was a small change that made the analysis possible.
Channel data also exposed missed demand. Patients who never completed a scheduled video visit often reappeared as no-shows or emergency department visits. Offering a phone fallback at the point of scheduling, and tracking how often it was used, showed where video was failing patients.
How phone visits fitted the workflow
A phone visit needs the same scaffolding as any other visit: scheduling, registration, consent, interpreter access, documentation in the EHR, correct coding, and a route to orders, prescriptions and follow-up. Many practices first ran phone visits outside normal workflows. Clinicians called from personal phones and documented afterwards. That produced gaps in records and caller ID problems when patients ignored unknown numbers. Adding an interpreter was awkward or impossible.
The better approach treated audio-only as a scheduled visit type in the EHR. Telephony showed a recognizable number, supported three-way calls with interpreters and logged the time and modality for billing. Small design choices made a visible difference. A reminder text the day before, a call from a known number and a stated time window all raised completion rates. Front-desk staff needed scripts for converting a video appointment to a phone visit when a patient struggled with the technology.
Follow-up needed equal care. A phone visit that ends with a lab order or a new prescription depends on the patient receiving instructions they cannot see on a screen. After-visit summaries had to go by mail, text or portal, in the patient’s language, with a number to call back.
Capacity planning changed as well. Phone visits shifted load from exam rooms to telephony and scheduling. Call queues, outbound line capacity and the number of interpreters available by phone now set how many patients a clinic could see. Operations leaders who tracked abandoned calls, interpreter wait times and visits started late could see those limits forming. Clinics that set aside protected blocks for phone visits, rather than squeezing calls between in-person appointments, ran closer to schedule and kept patients waiting less. Clinician experience mattered too. Many clinicians found back-to-back calls more tiring than they expected, without the cues of a room, and scheduling templates had to allow time for documentation between calls.
Which controls a low-friction channel required
Lower friction brings risk in four areas, each with its own control. Clinically, some conditions cannot be assessed without seeing the patient. Clinicians need written criteria for when to escalate to video or in-person care, and the EHR should make escalation a single step. Financially, audio-only services are easier to bill without adequate documentation, which attracts audit and fraud scrutiny. Documentation standards and periodic claim audits address that.
Identity is the third area. On a call, confirming that the person answering is the patient, or an authorized representative, needs a defined procedure rather than a clinician’s judgment in the moment. Two identifiers, checked the same way every time, are a reasonable baseline. Privacy is the fourth. Patients at home may be overheard, and staff calling from home must protect what they say and write. Asking at the start whether the patient can speak freely, and offering to call back, protects sensitive conversations.
These controls also make the channel adaptable. Payment rules for audio-only care were temporary, and they were likely to diverge across Medicare, Medicaid and commercial payers. A health system that ran phone care as a distinct, measured service could adjust which services it offered by phone as rules changed. One that had absorbed phone calls informally into clinicians’ days could not even see what it was doing.
With hindsight
Audio-only care proved durable for some services and contested for others. Through its rulemaking for 2022, CMS made audio-only delivery permanently available in certain circumstances for mental and behavioral health services furnished to patients at home. For many other Medicare services, audio-only coverage depended on temporary extensions Congress passed after the public health emergency ended. Many states also required Medicaid programs or commercial insurers to cover audio-only services.
CMS then went further. In the 2025 physician fee schedule, finalized in November 2024, it permanently allowed audio-only telehealth to patients at home. The condition is that the practitioner can offer video but the patient cannot use it or does not consent to it. That framing matches the argument here: the phone is a patient-chosen channel, and the record has to show why it was used. Oversight bodies, including the HHS Office of Inspector General, kept pressing for stronger documentation of how and why telehealth was delivered.