HHS-OIG Releases Toolkit for Assessing Telehealth Billing Risks

May 02, 2023 – A newly released federal toolkit aims to help healthcare stakeholders analyze their telehealth claims data to assess program integrity risks.

Released last week by the US Department of Health and Human Services (HHS) Office of the Inspector General (OIG), the toolkit is based on the methodology developed for a report published last September that assessed providers who billed Medicare for telehealth services. The previous report determined that of 742,000 providers billing for telehealth, 1,714 providers engaged in billing that posed a high risk to Medicare.

The new toolkit aims to help public and private sector partners, including Medicare Advantage plan sponsors, private health plans, and State Medicaid Fraud Control Units, assess the integrity risks associated with telehealth-related billing.

It details five steps stakeholders should take when analyzing telehealth claims:

1. Review the payment and coverage policies of the program being assessed.

2. Identify the claims related to telehealth services, which may vary according to the program’s coverage and billing policies.

3. Conduct quality assurance checks on the data, including checking for completeness and accuracy in data fields.

4. Use data analytics to determine program integrity risks, including providers that pose a high billing risk for programs.

5. Interpret the analysis results and implement safeguards, such as pre- or post-payment edits for providers that exceed certain thresholds.

The toolkit also provides seven measures that stakeholders can use to analyze claims data:

• Measure 1: Identifies providers who bill for telehealth services at the highest, most expensive level every time.
• Measure 2: Identifies providers who bill for a high average number of hours of telehealth services per visit.
• Measure 3: Identifies providers who bill for telehealth for a high number of days.
• Measure 4: Identifies providers who bill for a high number of unique patients.
• Measure 5: Identifies providers who bill multiple plans or programs for the same telehealth service for a high proportion of their services.
• Measure 6: Identifies providers who bill for telehealth services and order medical equipment and supplies for a high percentage of their patients.
• Measure 7: Identifies providers who bill for a telehealth service and a facility fee for most visits.

“Gaining a better understanding of the program integrity risks associated with telehealth services can help policymakers and stakeholders develop necessary safeguards and address individual cases of potential fraud, waste, and abuse,” the OIG stated.

The dramatic increase in telehealth usage during the COVID-19 pandemic prompted federal agencies, such as the OIG, and watchdog groups to look closely at potential fraud, abuse, and waste within the arena.

In December, the Pandemic Response Accountability Committee’s (PRAC) Health Care Subgroup published a report examining telehealth use within selected healthcare programs across six federal agencies during the first year of the pandemic.

Overall, the agencies spent more than $6.2 billion on telehealth services. But there were several similar program integrity risks associated with billing for telehealth services, according to the report.

The risks included “upcoding” telehealth visits by billing for visits longer than they lasted, duplicate billing for the same service, and ordering unnecessary durable medical equipment (DME), supplies, or laboratory tests.

In addition, the Department of Justice (DOJ) has increasingly cracked down on fraud, waste, and abuse related to telehealth services in the past few years.

Last July, the DOJ filed criminal charges against 36 defendants in telehealth-enabled fraud schemes involving illegal kickbacks for genetic testing and DME, leading to more than $1.2 billion in losses.

The defendants included a telemedicine company executive and the owners and executives of several clinical laboratories, DME companies, marketing organizations, and healthcare professionals spanning 13 federal districts.