The Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) recently released a toolkit regarding analysis of telehealth claims to assess program integrity risks. Use of telehealth services exploded during the pandemic, with Medicare beneficiaries in particular using 88 times more telehealth services in the first year of the pandemic than in the year prior. In the toolkit, OIG outlined its approach to analyzing telehealth claims, ostensibly in an effort to help Medicare Advantage plan sponsors, private health plans, State Medicaid Fraud Control Units, and other Federal health care agencies analyze telehealth claims data. Therefore, healthcare providers may see this type of analysis in other contexts or use this type of analysis for their own compliance purposes.
Specifically, OIG is performing data analysis on Medicare and Medicare Advantage claims for telehealth services and has identified seven measures that OIG believes may indicate fraud, waste, or abuse, as well as thresholds where OIG believes these measures signify “high risk.”
• Billing telehealth services at the highest, most expensive level for a high proportion of services, including E/M services. OIG considers providers to be high risk if they billed 100 percent of their telehealth services at the highest level.
• Billing a high average number of hours of telehealth services per visit. OIG considers a provider to be high risk if they billed for an average of more than 2 hours of telehealth services per visit.
• Billing telehealth services for a high number of days in a year. OIG considers a provider to be high risk if they billed telehealth services for more than 300 days in the year.
• Billing telehealth services for a high number of patients. OIG considered a provider to be high risk if they billed telehealth services for 2,000 or more beneficiaries.
• Billing multiple plans or programs for the same telehealth service for a high proportion of services. OIG considers a provider to be high risk on this measure if they billed both Medicare fee-for-service and a Medicare Advantage plan for the same service for more than 20 percent of their services.
• Billing for a telehealth service and then ordering medical equipment for a high percentage of patients. OIG considers a provider to be high risk if they billed for a telehealth service and then ordered medical equipment and supplies for at least 50 percent of their beneficiaries.
• Billing for both a telehealth service and a facility fee for most visits. OIG considers a provider to be high risk if they billed for both a telehealth service and an originating site facility fee for more than 75 percent of their visits.
Certain providers will fall into “high risk” categories simply by nature of their practice or patient base. These providers should consider placing additional focus on compliance efforts in case the provider’s claims come under greater scrutiny. Conversely, providers whose billing practices fall below OIG’s “high risk” thresholds should not consider themselves immune from scrutiny, especially where a provider’s claims demonstrate more than one of the factors listed above.
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 email@example.com.