OIG Telehealth Fraud Concerns

From PAAS National LLC, published Oct. 27: In September 2022, the U.S. Department of Health and Human Services Office of Inspector General (OIG) put out a report¹ on program integrity risks concerning Medicare telehealth services during the first year of the COVID-19 pandemic. The OIG states that in the first year of the pandemic, more than 28 million Medicare beneficiaries (roughly 2 in 5) used telehealth — amounting to a dramatic 88-fold increase from the previous year. Because of this, the OIG wanted to find out if providers were appropriately billing telehealth services, while looking to identify the best way to further protect the Medicare program and beneficiaries from fraud, waste, and abuse (FWA).

The OIG did some brief data analysis of telehealth claims from March 1, 2020 through February 28, 2021 of 742,000 providers. They found that 1,714 providers posed a high risk to Medicare due to concerning billing practices like billing for services that were not medically necessary or that were never provided. Other reasons for scrutiny included being in the same medical practice as another provider who engaged in high-risk billing practices (i.e., guilt by association).

High-risk providers were identified by the OIG when they billed:

• Both a telehealth service and a facility fee for most visits
• Telehealth services at the highest, most expensive level every time
• Telehealth services for a high number of days in a year
• Both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services
• A high average number of hours of telehealth services per visit
• Telehealth services for a high number of beneficiaries
• For a telehealth service and ordering medical equipment for a high proportion of beneficiaries

The OIG’s recommendations to CMS included strengthening target oversight and monitoring of telehealth services, providing education on appropriate billing for providers, improving transparency, identifying companies who provide telehealth to Medicare beneficiaries, and following up with providers identified in the OIG report as high risk.

PAAS Tips:

• Knowing if a telehealth visit is legitimate is difficult, so it is important to evaluate the patient/prescriber/pharmacy relationships; PAAS Audit Assistance³ members can refer to the November 2021 article, Telemedicine Audits: Are Your Prescriptions Legitimate?² in the PAAS Member Portal for a list of questions to consider when identifying if these relationships are valid
• Ensure you have a robust FWA program. Add the PAAS National® FWA program today by contacting us at info@paasnational.com or (608) 873-1342

PAAS National® is committed to serving community pharmacies and helping keep hard-earned money where it belongs. Contact us today at (608) 873-1342 or info@paasnational.com to see why membership might be right for you.

By Trenton Thiede, PharmD, MBA, President at PAAS National®, expert third party audit assistance and FWA/HIPAA compliance.
Copyright © 2022 PAAS National, LLC. Unauthorized use or distribution prohibited. All use subject to terms at https://paasnational.com/terms-of-use/.

References:

• https://oig.hhs.gov/oei/reports/OEI-02-20-00720.pdf
• https://portal.paasnational.com/Paas/Newsletter/Go/924
• https://paasnational.com/audit-assistance/