HHS OIG has said that during 2020, the use of telehealth services increased dramatically, with Medicare beneficiaries using 88 times more telehealth services in that year than the year prior. Additionally, more than 40% of Medicare beneficiaries used telehealth services that year.
The United States Department of Health and Human Services Office of Inspector General (HHS OIG) recently released a new toolkit to help ensure telehealth services are being provided in a safe and effective manner. The toolkit is meant to provide information on how to analyze telehealth claims to identify Medicare program integrity risks associated with telehealth services.
Specifically, the toolkit aims to provide policymakers and stakeholders, including Medicare Advantage plan sponsors, private health plans, and State Medicaid Fraud Control Units, with tools they need to identify program integrity risks associated with telehealth while ensuring that patients continue to receive high-quality health care and that health care providers remain accountable for the care they provide. The toolkit also provides a better understanding of the risks associated with telehealth services and how to address them.
The toolkit includes detailed descriptions of seven data analysis measures that can be applied to the user’s own data. The measures focus on different types of billing for telehealth that providers may use to inappropriately maximize their payments. Users are able to modify the measures to meet their individual need, such as identifying providers at varying levels of risk. The results can be used to help the user identify areas of risk where additional safeguards may be needed, or identify providers who warrant further scrutiny.
The steps to analyze telehealth claims include: (1) reviewing program policies to familiarize the payment and coverage policies of the program being reviewed; (2) collect claims data by identifying telehealth claims, the process of which may vary depending on the coverage and billing policies of the program; (3) conduct quality assurance checks on the data; (4) analyze the data to identify program integrity risks – using the seven program integrity measures outlined in the toolkit and summarized below; and (5) interpret the results of the analysis to identify any program integrity risks.
The seven program integrity measures identified below are expounded upon in the toolkit, including how to calculate the measure and how to identify providers who pose a risk to the program using each measure.
- Billing telehealth services at the highest and most expensive level for a high percentage of services (especially if the provider does this 100% of the time with telehealth services, as most providers rarely – if ever – do this)
- Billing a high average number of hours of telehealth services per visit (especially if the provider bills an average of more than 2 hours of telehealth services per visit)
- Billing telehealth services for a high number of days in a year (particularly more than 300 days in a year)
- Billing telehealth services for a high number of patients (particularly 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 (potential intentional duplicate claims)
- Billing for a telehealth service and then ordering medical equipment for a high percentage of patients (particularly if the provider bills telehealth service and medical equipment for 50% or more of their beneficiaries)
- Billing for both a telehealth service and a facility fee for most visits (particularly if they do this more than 75% of their visits as most providers do not do this).
In addition to providing more specifics on the seven measures listed above, the toolkit also includes additional steps and modifications that can be made in the analysis.
As is often the case, the toolkit is meant to serve as a resource and is not intended to create any rights, privileges, or benefits, and may not be error-free. The toolkit should not be used as the sole basis to determine whether an individual is inappropriately billing for telehealth services, nor is it meant to be used to determine compliance with laws, regulations, or guidance.