By JENNIFER COLAGIOVANNI, ESQ
Wachler & Associates, P.C.
The pandemic changed the relationship between patients and their healthcare providers, and telehealth use surged during the COVID-19 pandemic. Specifically, Medicare beneficiaries used telehealth services 88 times more often during the first year of the pandemic than in the year prior.  Medicaid and private health plans saw similar growth in the use of telehealth.  With this growth came concerns about the risks of fraud, waste, and abuse. The Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) recently released a toolkit setting forth methods to analyze telehealth claims and identify risks associated with telehealth services in the wake of the COVID-19 pandemic.

The toolkit is designed to assist public and private plans with oversight efforts and additional safeguards. The OIG toolkit provides an approach for analyzing claims data to identify potential areas of program integrity risk associated with telehealth, including seven program integrity measures that may further indicate fraud, waste, and abuse.  Developed based on analysis of both Medicare fee-for-service and Medicare Advantage claims, the seven measures focus on different billing practices that may indicate efforts to inappropriately maximize telehealth payments.  And while the toolkit is written as guidance to public and private stakeholders, these measures provide valuable insights and compliance metrics for providers to proactively evaluate the risks associated with the use of telehealth in their practices.

In the OIG’s analysis of telehealth services, it identified measurable thresholds that might further flag healthcare providers as “high risk” and call for additional scrutiny and safeguards.  From a compliance standpoint, awareness and assessment of these measures may offer insight into potential areas of concern in a provider’s or practice’s use of telehealth.

  • Billing telehealth services at the highest, most expensive level for a high proportion of services. This measure is aimed at identifying providers billing for higher levels of service than provided, also known as “upcoding.” Understanding the proportion of claims billed at the highest levels can provide valuable insights for a practice to identify potential compliance enhancements in order to proactively steer clear of potential audit scrutiny.

 

  • Billing a high average number of hours of telehealth services per visit. The OIG considers a “visit” to be all the telehealth services a provider billed for a single beneficiary for one date. Billing for a high average number of hours per telehealth visit can indicate risks associated with billing for unnecessary services or services not rendered.   Likewise, auditors may consider applying an “impossible day” analysis, which can identify providers who bill for an impossible or improbable number of hours in a single day.

 

  • Billing telehealth services for a high number of days in a year. The OIG considers a provider to be high risk if they billed Medicare telehealth services for more than 300 days in the year, which is significantly higher than the median of 26 days per year.

 

  • Billing telehealth services for a high number of patients. The OIG considers a provider to be high risk if they billed telehealth services for 2,000 or more beneficiaries, specifically “unique” patients. Billing for a high number of unique patients may signify providers as “high risk.” To avoid further scrutiny based on this measure, it may be prudent for healthcare providers to ensure they are not billing telehealth services solely, or primarily, for patients with whom they do not have an “established relationship.”

 

  • Billing multiple plans or programs for the same telehealth service for a high proportion of services. The OIG considers providers to be high risk if they billed both Medicare fee-for-service and a Medicare Advantage plan for the same service for more than 20 percent of their services. It is important for healthcare providers to proactively ensure that telehealth services are being billed only to the patient’s applicable payer or risk inviting further scrutiny.

 

  • Billing for a telehealth service and then ordering medical equipment for a high percentage of patients. The OIG is particularly concerned about this practice because it is often linked to known fraud schemes. The OIG considers a provider to be high risk if they billed for a telehealth service and then ordered medical equipment and supplies for at least 50 percent of their beneficiaries.

 

  • Billing for both a telehealth service and facility fee for most visits. A facility fee is a fee that a health care facility can charge when a patient comes to its building to receive telehealth services from a provider located elsewhere. Essentially, this facility fee reimburses the facility for hosting the patient. Typically, a provider may not bill both the telehealth service and the facility fee under Medicare and the OIG considers a provider to be high risk if they billed for both a telehealth service and an originating site facility fee for more than 75 percent of their visits.

While the OIG toolkit set forth thresholds from a program integrity standpoint based on Medicare claims analysis, other public and private stakeholders are encouraged to adjust the thresholds to fit their needs and data analysis objectives. While these thresholds may aim to identify high risk providers, providers who fall below the “high risk” categories should not necessarily consider themselves free from any increased scrutiny.  Instead, providers are advised to independently utilize these measures to assess compliance considerations in their use of telehealth services. Telehealth services are here to stay for the long run, and it is crucial for healthcare providers to analyze their telehealth programs to ensure compliance.