In this article you’ll discover what the OIG found when investigating telehealth billing fraud, what they recommend regarding future CMS oversight, and four critical takeaways for businesses billing Medicare for telehealth services.

As part of its published 2021 Workplan, the U.S. Department of Health and Human Services’ Office of Inspector General (“OIG”) analyzed individual practitioner Medicare fee-for-service “telehealth” claims data along with telehealth encounters from Medicare Advantage plans from March 1, 2020, to February 28, 2021, to determine whether the dramatic increase of telehealth services during the COVID-19 Public Health Emergency presents a significant program integrity risk to the Medicare program (the “Program Integrity Review”).

The telehealth claims and encounter data included virtual care and communication technology-based services, such as virtual check-ins, e-visits, remote patient monitoring, and audio-only communications from 741,750 providers.

Suspect Telehealth Billing Practices

During the Program Integrity Review, OIG identified seven billing practices that providers used to inappropriately bill Medicare for telehealth services.

The 7 Inappropriate Billing Practices include:

1. Billing both a telehealth service and a facility fee for most visits;

2. Billing telehealth services at the highest, most expensive level every time;

3. Billing telehealth services for a high number of days in a year;

4. Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services;

5. Billing a high average number of hours of telehealth services per visit;

6. Billing telehealth services for a high number of beneficiaries; and

7. Billing for a telehealth service and ordering medical equipment for a high proportion of beneficiaries.

Out of the 741,750 providers who submitted telehealth claims to Medicare from March 2020 through February 2021, OIG identified only 1,714 providers (i.e., 0.0023% of all telehealth providers) whose billing included one of the above-suspect practices. These 1,714 providers billed for half a million beneficiaries and received a total of $127.7 million in Medicare fee-for-service payments. OIG determined that many of the high-risk providers are a part of the same medical practice as at least one other provider whose billing poses a high risk.

OIG Recommendations and CMS Response

Despite the number of high-risk providers representing a small percentage of all Medicare telehealth providers, OIG emphasized the importance of targeted oversight of telehealth to minimize program integrity risk while ensuring patient access to the benefits of telehealth. 

OIG specifically recommended that CMS take the following actions:

1. Strengthen monitoring and targeted oversight of telehealth services;

2. Provide additional education to providers on appropriate billing for telehealth services;

3. Improve the transparency of “incident to” services when clinical staff primarily delivered the telehealth service;

4. Identify telehealth companies that bill Medicare; and

5. Follow up on the identified high-risk providers.

Interestingly, CMS only concurred with OIG’s fifth recommendation to follow up on the high-risk providers and did not explicitly take a position on the other four recommendations. While CMS acknowledged the legitimacy of OIG’s concerns that led to the other recommendations, it stated that it would need additional time to analyze the data before it could determine whether to concur with OIG’s other recommendations.

Key Takeaways for Billing Medicare Telehealth Services

• Complexity of the Beneficiary’s Condition Should Guide Billing Decisions

  • OIG states that “[b]illing for the highest level of complexity or duration when that is not what was needed or provided is one scheme that unscrupulous providers use to inappropriately increase their Medicare payments.”

    • Make sure that clinical documentation justifies the duration of and selection of the telehealth service, the billing code(s), and medical necessity.

• Top Volume Providers are Inherently Deemed High-Risk by OIG

  • OIG provided numerous examples of providers billing for lengthy telehealth service appointments (2 hours up to 10 hours per beneficiary appointment) and a high number of beneficiaries. In one case, a provider billed for so many beneficiaries that the provider would have had to have seen an average of 12 new beneficiaries every single day for a year. OIG stated that even if these services were provided, the volume of billing raises serious concerns about the quality of care.

    • Make sure that patient selection is a deliberative process and clinically justified, and that the level of service is based on patient-specific clinical circumstances.

• Document Clinical Staff Involvement with Telehealth Services Thoroughly

  • OIG considers the identification of the individual who delivered the telehealth service essential to its program integrity efforts and states that current Medicare billing data makes it difficult to determine when telehealth services were provided by the physician or when services were rendered by clinical staff “incident to” a physician. Additionally, Medicare billing data does not reveal whether an individual providing a service under a physician’s supervision has been terminated from Medicare or excluded from participation in Federal healthcare programs. OIG states that in past program integrity review(s), “incident to” services provided in person were frequently delivered by practitioners who lacked the licenses, certifications, credentials, or training required for those services.

    • Make sure that the right level of clinical staff is utilized for services performed under the relevant state’s scope of practice, that appropriately licensed and experienced individuals are utilized, and that clinical staff services are always well documented.

• As the Major Enforcement Agency for Medicare Programs, OIG Believes Targeted Oversight Is Necessary

  • To limit the risk of being subject to enforcement agency scrutiny, make sure that your telehealth providers or customers are educated on telehealth billing practices to avoid.

Would Your Telehealth Billing Practices Withstand an Audit?

Given NGL's deep expertise in the evolution of regulatory policies, we are incredibly well positioned to defend telehealth, digital health, and virtual care management audits and investigations. And we do.

This expertise led us to develop a system of proactive steps to identify, mitigate, and close compliance gaps in billing, claims, and the patient selection process. This system helps clients minimize individual and corporate liability risk (civil and criminal) and financial exposure.

If you want to confidently bill telehealth services while ensuring you are prepared to withstand an enforcement agency inquiry or subpoena, click the button below to schedule a brief call for more details.