FWA Briefs

Find news and solutions for healthcare payers and providers. Recognize and avoid potential fraud, waste, and abuse scenarios. Real-time clinical claim editing are analyzed to maximize provider reimbursements.

Keeping a watchful eye on telehealth claims

  • by Cindy Gallee, JD, RHIA, CHC
  • Jun 5, 2018, 11:00 AM

Telemedicine has grown significantly in recent years due to new technologies and consumer demand.  According to an April 2017 study by Grand View Research, the telemedicine market is expected to grow to $113.1 billion by 2025 with an estimated compound annual growth rate (CAGR) of 18.8%.  An anticipated 7 million patients in the U.S. will access telemedicine services in 2018, a sharp increase from 350,000 in 2013.  Payer reimbursement policies, on the other hand, are slow to adapt to the new services.

This article describes policy and reimbursement issues for telehealth and telemedicine services, which occur when the physician or other healthcare professional and the patient are not at the same site.  In 2015, CMS paid $17.6 million for telehealth, which is over $17 million more than it paid just 4 years before.  Commercial payers are also covering telehealth, but with varying rules.  Which procedure codes are covered as telehealth, which facilities qualify as originating sites, whether a modifier is required, and the correct place of service are all issues that need to be addressed in commercial policies.  In general, telehealth payments include a professional fee to the provider of the covered service at the distant site and a facility fee to the eligible originating site where the patient is located.   

Given the ambiguity and disparate rules in telehealth, it is ripe for FWA.   The OIG recently found in a review of CMS telehealth payments that more than half of the professional claims reviewed did not have a matching claim for the originating site facility.  Additional issues included inaccuracies in the professional claims as well, such as:  ineligible originating site, ineligible distant site, incorrect means of communication, or non-covered service. 

For Medicare and most commercial carriers, the originating site (where the patient is located) can’t be the patient’s home.  The originating site must be rural and one of the following: 

  • provider’s office
  • hospital
  • critical access hospital (CAH)
  • rural health clinic
  • federally qualified health center
  • hospital-based or CAH-based renal dialysis center
  • skilled nursing facility
  • community mental health center

In addition, telephone or online services such as a provider taking an after-hours call from a patient, are not covered telehealth services and will not be reimbursed.  Instead, telephone services billed with CPT 99441-99444 or CPT 98966-98968 are generally considered part of overall patient management and are not covered services.  Payers should have clear policies on these services.

Context Payment Integrity can facilitate review of telehealth claims to detect irregularities in billing:

  • There must be both a professional claim for the covered telehealth service and a facility claim from the originating site.
  • The service must be covered.
  • The originating site must be rural and be an eligible site.
  • Payer policy must be followed as to modifier and/or place of service.
  • Payer policy must be followed as to allowed frequency of services.

The system will also detect irregularities related to utilization, unnecessary services, unbundling and a variety of issues in the delivery of professional services.

At Context4 Healthcare, we can simplify the review process for telehealth claims.  We edit for valid modifier, valid place of service, covered telehealth service, and allowed frequency.  We also have an edit for making sure that a professional claim for telehealth services has an accompanying facility claim for the originating site.  Our innovative SaaS service is real-time, secure and scalable as delivered through the AWS Gov Cloud.

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