Skip Navigation LinksHome | Editors' Blog | Post

OIG to CMS and legislators: Build program integrity into any new telehealth rules

While legislators and policy creators debate permanent changes to Medicare’s telehealth rules, the HHS Office of Inspector General (OIG) issued a call to build program integrity protections into any changes.The agency included the reminder in its Sept. 2 data brief, Medicare telehealth services during the first year of the pandemic: Program integrity risks.
“As permanent changes to telehealth are considered, it is essential that CMS, Congress, and other stakeholders incorporate targeted, appropriate safeguards to prevent, detect, and remediate the program integrity risks identified in this report,” the OIG states.
The OIG used Medicare data and input from investigators to create seven program integrity measures that “focus on different types of billing that providers may use to inappropriately bill for telehealth services.” The agency also created thresholds for each measure that “may indicate possible fraud, waste, or abuse” and provided information about normal billing patterns. The OIG found that aberrant telehealth claims tended to have the following characteristics:
  1. Billing a telehealth service and a facility fee for at least 75% of visits. According to the OIG, “most providers never billed this way.”
  2. Billing the highest level for office, nursing home, residential and home telehealth visit. Most providers “rarely, if ever” billed the highest-level visit for a telehealth service in these settings, the OIG said.
  3. Billing telehealth services for more than 300 days in a year, which works out to an average of 25 days a month. The median for the review period was 26 days in a year.
  4. Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for more than 20% of services. Most providers never billed this way, according to the OIG.
  5. Billing telehealth visits that averaged more than two hours per visit, compared to the median time of 21 minutes.
  6. Billing telehealth services for more than 2,000 beneficiaries. The median was 21 beneficiaries.
  7. Billing for a telehealth service and ordering medical equipment for at least 50% of their patients, compared to a median of 3%.
The OIG reviewed claims submitted by 741,759 doctors and qualified health care professionals and identified 1,714 providers whose billing exceeded the OIG’s thresholds for at least one measure. The OIG deemed those providers’ billing “posed a high risk to Medicare.” The data brief reviewed telehealth services from March 1, 2020, to Feb. 28, 2021.
While the agency reviewed only a small amount of providers performing telehealth services, the low number of problematic providers may not reflect the extent of the problem. The agency deliberately set a high bar for its thresholds and noted that the providers identified by the review represented extreme cases. Four examples from the report illustrate just how far from the norm some providers strayed:
  1. Two family practice providers billed nearly 18,600 services for slightly more than 1,800 beneficiaries, an average of more than 10 services per patient.
  2. A provider associated with a telehealth company billed for more than 27,400 patients. That would be an average of 75 patients a day every day of the year.
  3. Ten providers billed an average of at least three hours, which is eight times longer than the average visit.
  4. One provider billed the highest level for their telehealth home visits and billed prolonged services for more than 50% of the services.
The review did “not capture all concerning billing related to telehealth services that may be occurring in Medicare,” the OIG said. One area it couldn’t track was the extent of incident-to billing, which “creates challenges for oversight because it allows services provided by clinical staff who are directly supervised by a practitioner to be billed under the supervising practitioner’s identification number,” the OIG said.
It’s recommendations to CMS included creating a way to track incident-to services.
Blog Tags: anti-fraud, compliance, OIG
To comment, login here.
Reader Comments (0)


User Name:
Welcome to the new Part B News Online. If you are a returning user having trouble logging in, please click here.
Back to top