CMS tries to rein in dubious telehealth claims

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While the vast majority of providers billing for telehealth services do so in a way that poses no significant risk to Medicare, a small percentage of telehealth claims are problematic — and the Centers for Medicare and Medicaid Services are working to stem the problem. .

One possible area of ​​interest: More than half of providers whose billing practices raised red flags worked in medical practices in which at least one other physician filed similar complaints.

According to a new report from the Office of Inspector General of the Department of Health and Human Services, this trend suggests that some practices are encouraging such billing among their associated providers.

On top of that, 41 providers who engage in high-risk billing “appear to be associated with telehealth companies,” the report said. “However, there is currently no systematic way to identify these companies in Medicare data.”

Data was extracted from Medicare Pay and Medicare Advantage data from March 1, 2020 through February 28, 2021 from more than 742,000 providers. More than 28 million beneficiaries used telehealth services during this window.

Of those providers, 1,714 have billing that poses “high risk” to Medicare. These providers billed about half a million beneficiaries for telehealth services and collected nearly $128 million in fee-for-service payments through Medicare.


The OIG said various changes to Medicare’s telehealth policies, along with the dramatic increase in telehealth use, underscore the importance of determining whether providers charge for telehealth services appropriately and how to protect best Medicare and its beneficiaries against fraud, waste, and abuse. .

Using feedback from investigators, the agency developed seven metrics that focus on different types of billing for telehealth services that may indicate such fraud. Each of the 1,714 vendors identified as potentially problematic had billing issues on at least one of seven metrics. All merit further consideration, the OIG said; for example, they may charge for services that are not medically necessary or have never been provided.

Risk minimization can be achieved by conducting targeted surveillance, the OIG said.

To this end, he made a number of recommendations for CMS. He suggested the agency strengthen monitoring and targeted surveillance of telehealth services; provide additional training to providers on proper billing for telehealth services; improve the transparency of “incident” services when clinical staff mainly provide the telehealth service; identify telehealth companies that bill Medicare; and follow up on the suppliers identified in the report.

CMS agreed with the recommendation to follow up with affected vendors, but offered no opinion on the other recommendations.


Hospitals, provider groups and telehealth organizations are lobbying the US Senate to expand telehealth flexibilities, such as removing in-person requirements for virtual behavioral health and improving health access virtual on the commercial market.

As it stands, these policies – which were adopted in response to the COVID-19 pandemic – are due to expire 151 days after the end of the public health emergency. The PHE is currently scheduled to end in October, although health officials expect the Biden administration to extend the PHE at that time.

Other current telehealth flexibilities include provisions to waive provider and patient location limitations, and facilitate access to clinically appropriate controlled substances without in-person requirements.

Calling for a two-year extension of telehealth flexibilities, the organizations argued that virtual care is now a fundamental part of the US healthcare system — one that improves both access and continuity of care.

Despite the benefits of telehealth, there are also frustrations, according to a study recently published by UnitedHealth Group. The survey of 240 healthcare providers showed that a majority (69%) find telehealth convenient, but 28% described virtual care as frustrating.

Although these descriptors may seem contradictory, providers clarified their thinking, with 58% saying they were frustrated with the quality of care they can provide via virtual platforms, and 55% saying they have to manage patient expectations for virtual tours. Half of the respondents were unhappy with the technicalities of navigating telehealth.

Twitter: @JELagasse
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