The emergency is over, the hype has cooled, and telehealth has settled into something more useful: a scheduling and access tool that either earns its slot on the template or doesn’t. Here is how to tell which.
Key Takeaways
- Telehealth utilization has settled well above pre-pandemic levels but far below the 2020 peak, and it varies enormously by specialty.
- Whether virtual visits are profitable depends on payer policy, visit type, and schedule design, not on the technology.
- Telehealth earns its keep as a no-show reducer and capacity tool more often than as a standalone revenue line.
- Treat reimbursement policy as a moving target and re-verify payer rules at least annually.
In 2020, telehealth was a lifeline. In 2026, it is a line item, and it deserves to be managed like one. For a private practice, telehealth reimbursement now sits at the intersection of payer policy, scheduling discipline, and specialty fit, and owners who never revisited the economics after the public health emergency are usually running virtual visits at whatever margin chance assigned them. The question is no longer whether to offer telehealth. It is whether your version of it makes money.
The utilization data tells the story of the settling. CMS’s Medicare Telehealth Trends report shows usage peaked in the second quarter of 2020, when 47% of telehealth-eligible Medicare users had a virtual service, then leveled off to roughly 15% by the end of 2022, far above pre-pandemic levels but a fraction of the peak. Telehealth did not take over medicine. It found its niches.
Specialty fit is the first economic question
Those niches are sharply defined. An AMA analysis of 2024 Medicare claims found that only 3.7% of telehealth-eligible physician spending was billed as telehealth overall, but psychiatry billed 31.2% of eligible spending virtually, followed by endocrinology at 8.5%, neurology at 7.3%, and gastroenterology at 6.6%. The pattern is intuitive: specialties built on conversation, cognitive work, and medication management translate well to video. Specialties built on physical examination and procedures do not.
For a practice owner, this is the first filter. If your specialty’s national telehealth share is negligible, a large virtual program is probably fighting gravity. If you practice in a conversation-heavy specialty, the question shifts to which visit types belong on video: medication follow-ups, results reviews, chronic disease check-ins, and post-procedure touchpoints are the usual winners.
Telehealth reimbursement is policy, and policy moves
The economics of a virtual visit start with what you are paid for it, and that answer is less stable than most owners assume. Medicare’s post-pandemic telehealth rules have been extended, revised, and debated repeatedly; MedPAC’s status report to Congress is the reference document for where Medicare policy stands and where it is headed. Commercial payers set their own telehealth rates and coverage terms, and they do not all follow Medicare’s lead.
The practical discipline is unglamorous: build a payer-by-payer grid of your top telehealth codes, confirm coverage, rate, and any originating-site or modality rules, and refresh it at least annually. A virtual visit reimbursed at parity is a different business than one paid at a discount, and many practices discover only at year-end which one they were running.
Telehealth is not a strategy. It is a slot on your schedule template, and every slot either earns its keep or takes the place of one that would.
The margin math on a virtual visit
Compare a virtual visit to the in-person visit it displaces, not to zero. On the revenue side: the reimbursement for that code, from that payer, with any telehealth differential. On the cost side: physician time is identical, but rooming staff, supplies, and room turnover largely disappear, while platform fees and scheduling complexity appear. The swing factor most owners miss is attendance. Missed appointments cost practices roughly $200 or more in lost revenue apiece, according to statistics compiled by patient-communication vendor Dialog Health, and virtual visits are far easier for patients to keep: no drive, no parking, no half-day off work.
This is why telehealth usually pays off as an access and capacity tool rather than a standalone product. Filling late-cancellation holes with same-day virtual visits, converting high-no-show follow-up types to video, and offering evening virtual blocks that fill otherwise dead time all improve realized revenue per templated hour, which is the number that actually matters.
Work a real example from your own book. Take your most common established-patient follow-up code, your top payer’s rate for it delivered virtually, and the fully loaded cost of the slot. Then compare two scenarios: the visit conducted in person with your current no-show rate, and the same visit on video with a materially lower one. In most conversation-heavy specialties, the virtual slot wins not because it reimburses more, but because more of the scheduled visits actually happen. That is the honest economic case for telehealth in a private practice, and it is testable with your own data in an afternoon.
There is an equity dimension worth designing for as well. Federal survey analysis from HHS’s ASPE shows telehealth use varies by income, insurance status, and geography, which means the way you deploy virtual care shapes who can reach you. Practices serving rural or lower-income panels often find audio-visual barriers are real and plan visit types accordingly.
From the Field
A four-physician endocrinology group in the mid-Atlantic ran telehealth as an afterthought: virtual visits scattered through the day, no payer verification since 2021, and a 19% no-show rate on in-person medication follow-ups. Guidestone rebuilt the template with dedicated virtual blocks, converted routine follow-ups to video, and re-verified telehealth terms across the group’s top six payers, catching one commercial plan paying below the contracted rate. Within two quarters, follow-up no-shows fell under 8% and the group recovered roughly $11,000 a month in previously lost visit revenue.
Run telehealth like a service line, not a leftover
The practices that make virtual care profitable share a few habits. They schedule telehealth in dedicated blocks instead of sprinkling it between exams, because context-switching burns physician time. They assign specific visit types to video by protocol, so the front desk is not improvising. They track virtual visits as their own line in monthly reporting: volume, realized revenue per visit, no-show rate, and payer mix. And they revisit the payer grid every year, because telehealth reimbursement policy has changed repeatedly since 2020 and will change again.
Two housekeeping items belong on the same checklist. Licensure follows the patient, so a snowbird panel or a border-town location needs a policy for out-of-state visits before a physician improvises one. And documentation should capture modality and any payer-specific requirements on every virtual encounter, because a telehealth claim that cannot survive an audit is worse than no visit at all.
If nobody owns this analysis, it will not happen
None of this work is difficult. All of it is the kind of analysis that never gets done in a practice where the physicians are the only executives, because it sits below the urgency line every single week. A fractional COO or CFO makes it happen: the payer grid, the template redesign, the monthly report that says plainly whether virtual care carried its weight. Telehealth stopped being an emergency measure years ago. It is time it started being managed like the business line it became.
Sources
- CMS, Medicare Telehealth Trends Snapshot — https://data.cms.gov/sites/default/files/2024-09/c213a5e9-9e70-4b46-b5f1-2fb941ea0f6c/Medicare%20Telehealth%20Trends%20Snapshot%2020240827_508.pdf
- American Medical Association, “New data details how telehealth use varies by physician specialty” — https://www.ama-assn.org/practice-management/digital-health/new-data-details-how-telehealth-use-varies-physician-specialty
- MedPAC, “Telehealth in Medicare: Status report” — https://www.medpac.gov/wp-content/uploads/2023/10/Telehealth-April-2024-SEC.pdf
- ASPE (HHS), Household Pulse Survey telehealth brief — https://aspe.hhs.gov/sites/default/files/documents/7d6b4989431f4c70144f209622975116/household-pulse-survey-telehealth-covid-ib.pdf
- Dialog Health, “50+ Latest Patient No-Show Statistics” — https://www.dialoghealth.com/post/patient-no-show-statistics