Fraud, waste, and abuse (FWA) associated with telehealth services existed before COVID-19, but it significantly increased during the pandemic. An audit by the U.S. Health and Human Services Office of Inspector General (OIG) found that Medicare beneficiaries used 88 times more telehealth services during the first year of the pandemic than they did the previous year. The audit also identified 1,714 providers whose billing for telehealth services for about a half million beneficiaries during the first year of the pandemic posed a high risk to Medicare. Those providers received a total of $127.7 million in Medicare fee-for-service payments. There is also concern risky telehealth billing may increase into the future, as the volume of these services continues to increase.
As FWA continues to emerge, and poses more of a risk to organizational compliance, professionals should become familiar with some of the potential areas of noncompliance associated with telehealth. Here are three situations from the last few years where it was found, as well as some recent actions taken to safeguard against it.
Situation One: Before the Pandemic
In April 2019, government officials announced Operation Brace Yourself: a fraud takedown related to telemedicine and durable medical equipment (DME). The operation led to the arrest and prosecution of 24 defendants, including executives from five telemedicine companies, the owners of dozens of durable medical equipment (DME) companies and three licensed medical professionals. They were alleged to have paid doctors to prescribe DME with no patient interaction or only a brief telephonic conversation. Some defendants also allegedly controlled an international telemarketing network that obtained Medicare information from hundreds of thousands of elderly and/or disabled patients for the purposes of inappropriate billing.
Operation Brace Yourself was one of the largest healthcare fraud schemes investigated and prosecuted by enforcement agencies. It involved an estimated $1.2 billion loss, but the government also believes the takedown resulted in safeguarding more than $1.9 billion in Medicare funds for orthotic braces in the 20 months that followed.
Situation Two: During the Pandemic
During COVID-19, many states put non-emergency medical procedures and services on hold to prevent the spread of the virus. This had a material financial effect on many medical practices, because they could no longer continue their non-emergency, face-to-face services.
In response, one nationally recognized medical practice management company shifted its face-to-face evaluation and management visits to telehealth. It then allegedly directed its clinicians to see patients by telehealth twice each month, regardless of need, to make up for lost revenue – when prior to the pandemic the same patients only needed to be seen once per month. This practice settled these and other allegations by agreeing to pay over $24 million.
Situation Three: During the Pandemic
In addition, during the pandemic, some telehealth services that previously were only covered under relatively strict circumstances were covered more under temporary waivers. These actions led some providers to try to exploit the system. They allegedly referred Medicare beneficiaries to laboratories for expensive and medically unnecessary cancer and cardiovascular genetic testing for kickbacks. The $73 million fraud scheme was discovered and shut down.
Safeguarding Against FWA
These and other recent situations have led to significant improvements in telehealth service efficiency and delivery cost. Enforcement agencies also have announced several oversight measures to help curb FWA – a good thing considering the volume of telehealth services is expected to rapidly increase.
For example, OIG recently announced the release of a toolkit to assist the healthcare industry in analyzing telehealth claims to assess program integrity risks (see: https://oig.hhs.gov/oei/reports/OEI-02-20-00723.asp). The toolkit includes detailed descriptions of seven data analysis measures that can be applied to the user’s own data. Users can also modify the measures to meet their individual needs, such as identifying providers at varying levels of risk. The seven measures include:
- Billing both a telehealth service and a facility fee for most visits
- Billing telehealth services at the highest, most expensive level every time
- Billing telehealth services for a high number of days in a year
- Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services
- Billing a high average number of hours of telehealth services per visit
- Billing telehealth services for a high number of beneficiaries
- Billing for a telehealth service and ordering medical equipment for a high proportion of beneficiaries
The Inspector General herself recently gave a keynote address at the Health Care Compliance Association’s 2023 Compliance Institute. Among her remarks:
“As telehealth has become a bigger, more permanent part of health care delivery, we recognize stakeholders want more information about its potential risks and benefits. We have been conducting extensive reviews of telehealth in Medicare. Telehealth holds great promise for the efficient delivery of quality health care. But it behooves us all to be alert for possible fraud, waste, and abuse as this mode of delivery expands.”
Christi Grimm
Indeed, it behooves all compliance professionals to be aware of the fraud, waste, and abuse risks associated with telehealth services. As we’ve explored, this mode of delivery holds great promise. For it to fulfill that promise, noncompliance needs to be rooted out and corrected.
CJ Wolf, MD, M.Ed. is a healthcare compliance professional with over 22 years of experience in healthcare economics, revenue cycle, coding, billing, and healthcare compliance. He has worked for Intermountain Healthcare, the University of Texas MD Anderson Cancer Center, the University of Texas System, an international medical device company and a healthcare compliance software start up. Currently, Dr. Wolf teaches and provides private healthcare compliance and coding consulting services as well as training.
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