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Impact of Policy Adjustments on Telehealth Fraud

  • by Steve Nesnidal, MD, CPC, AHFI
  • Sep 10, 2021, 12:45 PM
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Early in the Coronavirus pandemic, telehealth restrictions were significantly relaxed by federal and most major commercial payers.  This enabled more types of services to be furnished remotely to more patients.  This action has helped to offset the decrease in face-to-face clinician visits necessary to limit viral spread in the non-emergent healthcare setting.  This explains why the share of all primary care services conducted by telehealth rose dramatically from less than 1 percent in January 2020 to 47 percent in April of 2020.   

On May 19, 2021, the Medicare Payment Advisory Commission (MedPac) provided feedback to Congress regarding their opinions on the effectiveness of the overwhelming 200 healthcare policy changes that Congress and CMS instituted during the interval of January through July 2020, in response to the coronavirus public health emergency.  Aside from the obvious and necessary benefits of these changes in response to the pandemic, MedPac raises concerns about the detrimental impact in the realm of fraud in healthcare: “…not all actors in the healthcare system are well-intentioned”.   

To further combat healthcare fraud in the realm of telehealth, MedPac recommends these three safeguards: 

  1. More closely scrutinize outlier clinicians, those who bill significantly more telehealth services per beneficiary than other clinicians.
  2. Require an in-person face-to-face visit before a clinician orders high-cost durable medical equipment (DME) or high-cost clinical laboratory tests
  3. Prohibit ‘incident to’ billing of telehealth services provided by any clinician who can bill Medicare directly 

Healthcare fraud in the Coronavirus Public Health Emergency (PHE), will undoubtedly rise and fall based on the opportunity afforded these “bad actors”.  All Payers, commercial and governmental, must adjust/modify policies as we transition out of the PHE.  The objective must be to retain the demonstrable benefits of telehealth while also minimizing opportunities for healthcare fraud, waste, and abuse. 

How to Protect Yourself from Fraud

Transitional telehealth policies will attempt to minimize fraud, but we know from recent trends that fraudsters will persist.  As with any audit, review for documentation that supports that the service was performed and for a medically necessary purpose, but also check for several fraud trends commonly seen with telehealth services:

  1. Look at the telehealth service volume performed by a given provider, relative to his/her in-person visits. This ratio will vary by specialty, quarter of year, and geographic region, but  compare the claims of your performing provider to appropriate norms.  If you detect a provider with significant outlying telemedicine services, we recommend you audit the medical records supporting a sample of their claims.
  2. Some payer policies require telecommunication between provider and beneficiary to occur real-time with both video and audio components for select services, others allow audio only.  Certain policies also have specific security and documentation requirements. Confirm that the details of a given encounter satisfy that payer’s reimbursement rules for that service in that timeframe.   
  3. If technical issues with the remote connection prevented a provider from interacting with the beneficiary, that should not support billing any telemedicine service.  Make sure your audit documentation reveals that the provider communicated with the beneficiary successfully.   
  4. Look for “phantom billing” (billing even though the patient missed the appointment).
  5. Look for upcoding of the time spent/level of service/type of service performed.
  6. Make sure the billing provider is eligible in location.   
  7. If found, also review additional related services (performed on same patient by same provider), known to be associated with fraudulent billing, like:
    • genetic testing and other high-dollar pathology tests
    • durable medical equipment (DME)
    • prescribed pain medications 

How Context 4 Healthcare Fights Fraud

Context 4 Healthcare will continue to optimize our FWA detection tools.  We will monitor policies related to the Coronavirus PHE, including telehealth changes.  Our FWA reports will serve as tools for our users to unearth outlying patterns of fraud, waste and abuse in both telehealth and related services. We will also adjust our myriad of telehealth fraud waste and abuse edits as these telehealth policies adapt, to provide optimal FWA detection during this transition and beyond.  Call us or visit our website if you’d like more information about our FWA suite of tools. 

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