CMS attempting to curb dubious telehealth claims

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While the vast majority of providers billing for telehealth services do so in a way that poses no significant risk to Medicare, a small percentage of telehealth claims are problematic – and the Centers for Medicare and Medicaid Services is looking to curb the issue. 

One possible area of focus: More than half of the providers whose billing practices raised red flags worked in physician practices in which at least one other doctor filed similar claims. According to a new report from the Department of Health and Human Services' Office of the Inspector General, this trend suggests some practices are encouraging such billing among their associated providers.

On top of that, 41 providers who engage in high-risk billing "appear to be associated with telehealth companies," the report read. "However, there is currently no systematic way to identify these companies in the Medicare data."

The data was culled from Medicare fee-for-service and Medicare Advantage data from March 1, 2020 to February 28, 2021 from more than 742,000 providers. In excess of 28 million beneficiaries utilized telehealth services during that window.

Of those providers, 1,714 were found to have billing that poses a "high risk" to Medicare. Those providers billed for telehealth services for about half a million beneficiaries, and collected close to $128 million in Medicare fee-for-service payments.

WHAT'S THE IMPACT?

OIG said that various changes to Medicare telehealth policies, along with the dramatic increase in the use of telehealth, underscore the importance of determining whether providers are billing appropriately for telehealth services, and how best to protect Medicare and its beneficiaries against fraud, waste and abuse.

Using input from investigators, the agency developed seven measures that focus on different types of billing for telehealth services that may indicate such fraud. Each of the 1,714 providers identified as potentially problematic had concerning billing on at least one of the seven measures. All warrant further scrutiny, said OIG. For instance, they may be billing for services that are not medically necessary or were never provided.

Minimizing risk can be achieved by conducting targeted oversight, said OIG.

To that end, it issued a number of recommendations for CMS. It suggested the agency:

• strengthen monitoring and targeted oversight of telehealth services.
• provide additional education to providers on appropriate billing for telehealth services.
• improve the transparency of "incident to" services when clinical staff primarily delivered the telehealth service. 
• identify telehealth companies that bill Medicare.
• follow up on the providers identified in the report.

CMS concurred with the recommendation to follow up with the relevant providers, but offered no opinion on the other recommendations.

THE LARGER TREND

Hospitals, provider groups and telehealth organizations are pressing the U.S. Senate to extend telehealth flexibilities, such as removing in-person requirements for virtual behavioral health and increasing access to virtual health in the commercial market.

As it stands, those policies – which were enacted in response to the COVID-19 pandemic – are set to expire 151 days after the end of the public health emergency. The PHE is currently set to end in October, though health officials are expecting the Biden administration to extend the PHE at that time.

Other current telehealth flexibilities include provisions to waive provider and patient location limitations, and to facilitate access to clinically appropriate controlled substances without in-person requirements.

In calling for a two-year extension of the telehealth flexibilities, the organizations have argued that virtual care is now a fundamental part of the U.S. healthcare system – one that has been shown to improve both access and care continuity.

Despite the advantages of telehealth, there are also frustrations, according to recently released UnitedHealth Group research. The survey of 240 healthcare providers showed a majority (69%) consider telehealth to be convenient, but another 28% described virtual care as frustrating.

While those might seem like contradictory descriptors, providers shed some clarity on their thinking, with 58% saying they were frustrated with the quality of care they can provide through virtual platforms, and 55% saying they have to manage patient expectations for virtual visits. Half the respondents were vexed with the technical details that come with navigating telehealth.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com