7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Mar 28th, 2023

In September of 2022, the Office of Inspector General (OIG) released a report, “Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks” in which they identified that approximately two in five Medicare beneficiaries used telehealth services within the first year of the pandemic to receive healthcare services from a Medicare provider. This is approximately 88 times more often than beneficiaries engaged through telehealth services prior to the pandemic.

Why the OIG Performed This Review

To meet the demand for telehealth services by Medicare beneficiaries throughout the pandemic, many major changes to the rules governing for who, when, how, and where beneficiaries could receive telehealth services were changed dramatically. Even allowing for telehealth services to be received in the patient’s own home, likely one of the biggest benefits to Medicare beneficiaries. Because of these many changes, and the massive increase in the use of telehealth services, it became vital to safeguard Medicare from potential fraud, waste, and abuse (FWA) related to these services through a series of data analyses and audits. 

Seven Measures Applied in this Review

The U.S. Department of Health and Human Services (DHHS), with the input from OIG investigators and Medicare data, developed a set of seven measures they used in their review to root out and identify Medicare provider behavior that indicates potential FWA. These seven measures are as follows: 

1. Billing for both a telehealth service and a facility fee for the majority of visits
   • Calculated the percentage of visits that included both an originating site facility fee and a telehealth service and discovered it was billed this way for more than 75% of their visits.
2. Billing telehealth services at the highest, most expensive level, every time
   • Most providers rarely, if ever, bill at the highest level of service but these providers always billed the highest level of service in the office, nursing home, assisted living, and home settings.
3. Billing telehealth services for a high number of days
   • By reviewing claims over a one-year period, it was noted that these providers regularly billed more than 300 days of telehealth services when the median is just 26 days of the year.
4. Billing both Medicare fee-for-service (FFS) and a Medicare Advantage plan for the same service for a high proportion of services
   • Most providers never bill both Medicare FFS and MA plans for the same service; however, these providers billed more than 20% of their services this way.
5. Billing a high average number of hours of telehealth services per visit
   • The average length of a telehealth visit is just 21 minutes; however, these providers consistently billed for a two-hour visit, on average.
6. Billing telehealth services for a high number of benificiaries
   • The median number of beneficiaries for which a single provider bills telehealth services for in a single year is 21. These providers, on average, billed for telehealth services for 2,000 or more beneficiaries in a single year.
7. Billing for a telehealth service and ordering medical equipment for many of their beneficiaries
   • Occasionally providers may recommend certain durable medical equipment, compounded medications, or other supplies during a telehealth or in-person visit. However, these providers ordered these additional services, supplies, and/or equipment for more than half of the Medicare beneficiaries they performed a telehealth service on. 

What the Review Identified

This review of Medicare providers who performed telehealth services on Medicare beneficiaries revealed that out of the identified 742,000 providers who billed telehealth services during the timeframe of March 1, 2020 through February 28, 2021, a total of 1,714 providers demonstrated what the OIG considers to be “concerning billing on at lest 1 of 7 measures.” 

While the seven measures are not related to a solid claim of fraud, waste, or abusive billing habits, they make a good starting point for additional investigations to occur into these questionable billing practices. Interestingly, further scrutiny of the 1,714 providers revealed that more than half of them were actually part of a medical practice where at least one other Medicare provider already showed questionable billing practices, which posed a threat to Medicare. Additionally, based on the application of these seven measures applied to these 1,714 providers, it was noted that many of them may actually be associated with telehealth companies, which from past Department of Justice (DOJ) investigations, have been noted to act fraudulently. 

Providers Associated with Telehealth Companies May Pose a Higher Risk

As there is no systematic way to identify providers who are associated with telehealth companies within the current Medicare data, this appears to be something that needs to be evaluated and rectified. The OIG recommends two options: 

• Adding a taxonomy code that identifies telehealth companies on claims
• Updating the Medicare provider enrollment application to require telehealth companies to identify themselves when they enroll in Medicare

It is estimated these simple changes may then allow CMS to identify beneficiaries who receive telehealth services from providers who are associated with telehealth companies and ensure beneficiaries are not being taken advantage of or being put at risk by receiving care from other than their regular providers, which may be incomplete or lacking in quality. 

What Can Regular Providers Do to Support Their Valid Services

While this is just a quick review of some of the issues identified with telehealth service reviews, additional issues have been noted or identified as problematic for regulating and ensuring proper use of funding for Medicare beneficiaries, such as valid incident-to services and verification of when clinical staff vs physicians/nonphysician providers are performing telehealth services. As a matter of fact, the OIG has recommended to CMS that they consider the additional requirement of adding a modifier to a claim where incident-to services were performed. 

We recommend setting internal policies for performing, documenting, and coding all telehealth services to remain compliant with the payer contracts your organization honors. Carefully review the new Evaluation and Management (E/M) service changes for 2021 and 2023 to ensure the documentation supports the correct level of service reported, and all telehealth service requirements have been met. Do not engage or contract with questionable telehealth companies and definitely avoid prescribing additional services that are “recommended” by the telehealth company. Make sure to question the patient before signing off on a telehealth service to ensure they were not promised certain DME or supplies by a telehealth customer service agent prior to an encounter. Vetting the companies you work with to ensure your patients are receiving quality care is important when it comes to protecting your organization from accusations of fraud, or even the appearance of it. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.