Starting January 27, 2020, in response to the Novel Coronavirus pandemic, the Department of Health and Human Services (HHS) determined the existence of a public health emergency (PHE), evoking the Public Health Service Act (PHSA), Section 319. This 90-day PHE period has since been extended five times to date, and it will likely be extended further, through early 2022. 

The PHSA has temporarily altered healthcare delivery in various ways; for example, many telehealth restrictions have been relaxed, which is a necessary step to limit potential COVID-19 exposure in physician offices in the emergency period. With this change, unfortunately, the US Justice Department estimates telehealth-related fraud has expanded significantly since early 2020 – approximated at 4.5 billion dollars.

Sorting Through Payer Telehealth Policies

Commercial telehealth policy details are unique to the payer. Which services a provider may perform via telehealth varies by payer. Many generally follow the CMS telehealth procedures list, but there are some variations (additions/deletions). There are also significant variations among commercial payer policies regarding the acceptable virtual service delivery methods for telehealth benefits (i.e., audio/video or telephone only). Payers variably require reporting of specific modifiers/place of service (POS) to identify that a procedure was performed via telehealth.

Some payers require use of modifiers -most commonly 95, GT or GQ - as appropriate to relay telehealth performance details. Additionally, some payers require POS 02 to identify the place of service as telehealth, whereas others require the POS that defines the actual location the telehealth services were provided or received (e.g. 11 Office). 

Because of this significant variation in telehealth policies, the provider must be aware of the payer specific telehealth policy of each encounter, to properly document these services and withstand audit scrutiny. As we progress beyond a year in this PHE, OIG as well as private payers are increasing their audits of telehealth claims.

What Telehealth Auditors Look For

Whether a payer’s telehealth audit approach is random, or is generated after detection of an aberrant claim pattern (like abnormal frequency of telehealth encounters in PHE compared to pre-COVID-19 levels), auditors will review the claim patterns (codes, modifiers, POS) alongside the medical records to search for support of procedures billed. 

Although the details of payer policies vary, potential telehealth audit deficiencies can include:

• Evidence of inappropriate virtual service delivery method
• Asynchrony between customer and service
• Lack of secure technology
• Inadequate record of relevant details regarding the communication
• Lack of medical necessity
• Failure of virtual care to be performed by a licensed, registered provider acting within scope of practice for location

How Context⁴ Healthcare Helps Prevent Audit Deficiencies

Context⁴ Healthcare includes a suite of Fraud Waste and Abuse rules and reports designed to identify aberrant telehealth claim patterns. Call (800) 783-3378 or visit our website for details.