Telehealth fraud still a target for feds even as COVID-19 pandemic winds down

© U.S. Department of Health and Human Services Office of Inspector General

A new written toolkit offers insights about how federal regulators examine telehealth claims for fraud.

“Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks” was published this month by the U.S. Department of Health and Human Services’ Office of Inspector General (HHS-OIG).

“The goal of this toolkit is to provide an approach to analyzing claims data for telehealth to identify areas in which additional safeguards may be necessary,” said the introduction. “The analysis can also help identify providers whose billing may pose a risk and warrant further scrutiny.”

The intended users include Medicare Advantage plan sponsors, private health plans, state Medicaid fraud control units, and other federal health care agencies. Physicians, along with policymakers and other stakeholders, can use the information to develop safeguards that maximize telehealth services and minimize risks of waste, fraud, and abuse.

Red flags

The toolkit outlined seven program integrity measures to apply to telehealth claims data. Using them can identify areas of risk that may need additional safeguards, or identify providers who warrant further scrutiny.

“Through the use of proactive, data-driven analyses, including measures such as those detailed in this toolkit, public and private partners can more effectively identify potential fraud, waste, and abuse schemes in their health care programs,” the toolkit said.

The program integrity measures are:

• Billing telehealth at the highest, most expensive level 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 days in a year.
• Billing telehealth services for a high number of patients.
• Billing multiple plans or programs for the same telehealth service for a high proportion of services.
• Billing for a telehealth service and then ordering medical equipment for a high percentage of patients.
• Billing for both a telehealth service and a facility fee for most visits.

Growth in telehealth

By now it’s well-known that the COVID-19 pandemic changed how patients interact with physicians and other clinicians. “The use of telehealth services grew dramatically during the first year of the pandemic and is now an important part of our health care system,” said the toolkit, which listed Ann Maxwell, deputy inspector general for evaluation and inspections, as author.

Medicare beneficiaries used 88 times more telehealth from March 2020 to February 2021, the first year of the pandemic, compared to the year before. More than 28 million beneficiaries – more than two in five – used telehealth.

Medically underserved populations and those in urban areas were more likely to use it than other groups. Medicaid and private insurance plans also had “exponential” growth in telehealth use.

As a result, HHS-OIG developed seven program integrity measures as indicators of possible waste, fraud, and abuse, focusing on providers that inappropriately maximized payments. Those were outlined in an earlier report that became the foundation for the toolkit. It includes a bibliography of five other federal reports on telehealth use during the pandemic.