Wachler & Associates Health Law BlogOIG Releases Medicare Telehealth Program Integrity Report
Recently, the US Department of Health and Humans Services (HHS) Office of the Inspector General (OIG) released a data brief analyzing telehealth services covered by Medicare and related program integrity risks. OIG sought to evaluate the impacts on program integrity due to the regulatory flexibilities implemented during the COVID-19 pandemic and the corresponding spikes in utilization rates for telehealth services by Medicare beneficiaries. Of the 742,000 providers that OIG evaluated, 1,714 had “concerning billing” on at least one of the seven measures that OIG considers to be potential indicators of fraud, waste, and abuse. The data brief represents OIG’s latest effort to use data analytics to identify program integrity concerns and includes specific proposals to improve data quality to aid in program integrity efforts.
OIG identified seven measures that it views as posing high risk for fraud, waste, and abuse. It is worth noting that these integrity measures are related to, but different from, the seven measures OIG identified in a special fraud alert issued in July 2022 with respect to provider arrangements with telehealth companies. The seven measures that OIG identified in the data brief are as follows:
- Billing for both a telehealth service and a facility fee for most visits
- Always billing telehealth services at the highest, most expensive level
- Billing telehealth services for more than 300 days of the year
- Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services
- Billing more than two hours of telehealth services per visit
- Billing telehealth services for at least 2,000 beneficiaries in a year
- Billing for a telehealth service and ordering medical equipment for at least half of beneficiaries
OIG noted that the presence of any of these measures in a provider’s billing may indicate that the provider is billing for services that are not medically necessary or were never actually provided to the patient. Specifically, OIG is focusing efforts on identifying telehealth entities that are providing services by recommending that the Centers for Medicare & Medicaid Services (CMS) update the Medicare enrollment application to identify telehealth entities that enroll in the Medicare program. As the contours of the COVID-19 pandemic continue to evolve and impact the healthcare industry, providers should be aware of flexibilities that may be modified or cease to exist and update their billing practices accordingly. Providers should continue to ensure that telehealth services are properly billed in accordance with applicable billing policies.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to telehealth or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.