backOIG Publishes Report on Program Integrity Risks Related to Medicare Telehealth Services During the First Year of the Pandemic—On September 2, 2022, OIG published a report of its findings summarizing its investigation into whether providers appropriately billed for Medicare beneficiaries’ telehealth services. This report analyzed data from the period of March 1, 2020 to February 28, 2021. During the first year of the pandemic, about two in five Medicare beneficiaries used telehealth services. OIG identified 1,714 providers, out 742,000 reviewed, who posed a high risk to Medicare with their billing practices. OIG relied on seven indicators of fraud, waste, or abuse of telehealth services billing.
The seven indicators of fraud, waste, or abuse are as follows:
- 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; and
- billing for a telehealth service and ordering medical equipment for a high proportion of beneficiaries.
The 1,714 providers identified by OIG had billing issues in at least one of those categories, and 18 of these providers had potential billing issues in two categories. The 1,714 identified providers billed for about half a million beneficiaries for telehealth services and received $127.7 million in Medicare fee-for-service-payments. OIG reports that each of the 1,714 providers warrants further scrutiny.
A physician who provides a telehealth service may not bill for a facility fee. However, OIG found that 672 providers billed for both a facility fee and a telehealth service for a total of $14.3 million and 148,000 visits. Next, OIG found that 365 providers billed at the highest and most expensive level for certain telehealth services every time, a practice referred to as “upcoding.” OIG identified 21 medical practices that had multiple providers who always billed at the highest level for telehealth services, which may indicate a scheme to inappropriately increase Medicare payments. Investigating the third indicator of fraud and abuse, OIG determined that the median number of days billed for telehealth services is 26 per year. In contrast, OIG found 328 providers who billed for telehealth services in excess of 300 days per year.
OIG also found that 138 providers billed both Medicare fee-for-service and a Medicare Advantage plan for the same telehealth service for more than 20 percent of their telehealth services. Eighty-six providers billed for a high average of more than two hours of telehealth services per visit, compared to the median of 21 minutes per visit. OIG found 76 providers triggered the sixth indicator of billing for a high number of beneficiaries, and 67 providers triggered the seventh indicator of commonly billing for telehealth services and then ordering medical supplies and equipment for at least half their beneficiaries. OIG views billing medical equipment and supplies for a high percentage of beneficiaries as raising a concern about the existence of a potential fraud scheme. Billing for medical equipment and supplies after a telehealth visit created an added concern because of the lack of established relationship between the provider and the beneficiary.
As a result of its findings, OIG made several recommendations to CMS—that CMS strengthen monitoring and target oversight of telehealth services, provide additional education on appropriate billing for telehealth services to providers, improve transparency of “incident to” services when clinical staff delivered a telehealth service, and identify the telehealth companies that bill Medicare. OIG also recommended that CMS follow up on the providers identified in this report as posing a high risk to Medicare for fraud and abuse and that CMS take appropriate action.
CMS responded to OIG’s recommendations and agreed that CMS would review the providers identified as high risk to Medicare and follow up with them as necessary. With regard to the other recommendations, CMS did not indicate express concurrence.
The full text of the OIG Report, “Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks,” is available here.
Reporter, Kasey Ashford, Washington D.C., +1 202 626 2906, kashford@kslaw.com.