HHS-OIG shares findings from its review of potential fraud, waste, and abuse in Medicare billing for telehealth visits in the first year of the pandemic.
Since the onset of the COVID-19 pandemic, patient telehealth visits (i.e., remotely provided healthcare services) have increased dramatically. According to the U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”), data from the first year of the pandemic (i.e., March 1, 2020 to February 28, 2021) shows that “[m]ore than 28 million Medicare beneficiaries—about 2 in 5—used telehealth services that first year.” Additionally, “beneficiaries used 88 times more telehealth services during the first year of the pandemic than they did in the prior year.” Meanwhile, during this same time period, HHS both expanded telehealth access for Medicare beneficiaries, and Centers for Medicare & Medicaid Services (“CMS”) “temporarily paused several program integrity activities, including medical reviews of claims.”
Unsurprisingly, this all coincided with increased risk of fraud and abuse. In a report published this month, the HHS-OIG shares findings from its review of potential fraud, waste, and abuse in Medicare billing for telehealth visits in the first year of the pandemic. Notably, this report, entitled, “Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks” (the “Telehealth Report” here), reveals that for 1,714 providers (out of 742,000) their billing practices posed a “high risk” to Medicare, and on at least one of seven metrics HHS-OIG used, these providers demonstrated “concerning billing” potentially indicative of “billing for telehealth services that are not medically necessary or were never provided.” (This Report follows an HHS-OIG “Special Fraud” alert relating to telemedicine fraud risk released this summer, which we wrote about here.)
In light of these findings, HHS-OIG makes a number of recommendations to CMS that are discussed below. Most notably, HHS-OIG recommends—and CMS has agreed—that further investigation of the identified providers is warranted. The Telehealth Report’s findings and recommendations present an opportunity for healthcare providers—including physician practices and hospitals—to ensure appropriate billing for telehealth services for Medicare beneficiaries (as well as all other payors) and to carefully and regularly monitor reimbursement and policy changes that may impact delivery of care.
Telehealth integrity measures and investigation results
HHS-OIG used the following seven measures that they believe could suggest fraudulent, wasteful, or abusive Medicare telehealth practices:
Practical tips for proper telehealth billing
The HHS-OIG integrity measures and findings provide useful guidance for provider compliance, including the following:
Potential changes in telehealth policies
As the pandemic becomes an endemic and as technology continues to improve, it is likely that patients and providers will demand that telehealth services remain an integral part of the health care delivery system. Meanwhile, federal and state governments and payors will continue to seek opportunities to control costs and ensure all telehealth services are medically necessary and well documented. The Telehealth Report provides important guardrails for providers to ensure the appropriateness of telehealth services and may also incentivize policymakers in the public and private sectors to implement additional protections with respect to telehealth services.
Saul Ewing’s health care and white collar defense lawyers are available to assist in addressing these and other reimbursement and compliance issues confronting providers, hospitals, and practices.
Bruce D. Armon, a Partner and Chair in the Healthcare Practice at Saul Ewing, counsels clients on how federal and state health care laws affect health care providers and businesses.
Justin C. Danilewitz, a Partner in the White Collar and Government Enforcement Practice at Saul Ewing, is a former Assistant U.S. Attorney who represents physicians and practice groups in government investigations.
Virginia E. Hansen is an Associate in the Litigation Department at Saul Ewing.
See U.S. Department of Health and Human Services, Office of Inspector General, Data Brief:Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-20-00720 (Sept. 2022) (hereafter, the “Telehealth Report”) at 1, available at https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf.
See id. at 1-2.
 The Report notes that “[t]he vast majority (1,696) of the providers we identified had concerning billing on 1 of the 7 measures, while 18 providers had concerning billing on 2 measures. Each of these 1,714 providers warrant further scrutiny.”See id. at 5.Based upon our experience, the likelihood of the 18 providers receiving close attention by HHS-OIG is very high.
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