OIG Audit Backs Medicare Telehealth Integrity

However, 'high risk' providers billed the program for $127.7 million for telehealth services in the first year of the pandemic.

First the good news.

Only 1,714 of the 742,000 providers who billed Medicare and Medicare Advantage for telehealth services for about 28 million beneficiaries during the first year of the pandemic "posed a high risk" to the program integrity, a federal audit shows.

Now the not-so-good news.

These high-risk providers represent only 0.2% of the audit sample, but they billed for about 500,000 beneficiaries and collected $127.7 million in Medicare fee-for-service payments for care provided between March 2020 and February 2021, according to an audit by the Department of Health and Human Services, Office of the Inspector General.

The first year of the coronavirus pandemic saw massive infusions of federal money and relaxed oversight by HHS of telemedicine services, as more than 28 million Medicare beneficiaries —about 2 in 5 — used telehealth in that first year of the pandemic, about 88 times more than in the previous year.

Using Medicare claims and Medicare Advantage encounters data for the 12-month period, auditors flagged providers for violating one or more of seven measures developed by OIG investigators to identify high-risk billings for fraud, waste, or abuse. OIG says it "set very high thresholds to identify providers whose billing poses a high risk to Medicare."

Each of the 1,714 flagged providers hit on at least 1 of 7 measures and warrant further scrutiny. The report called for "targeted oversight of telehealth (to) help ensure the benefits of telehealth are realized while minimizing risk in an effective and efficient manner."

Auditors also recommend five steps HHS could take to improve program integrity:

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,
    
5. Follow up on the providers identified in this report.
    

"Although these high-risk providers represent a small proportion of all providers who billed for a telehealth service, these findings demonstrate the importance of strong, targeted oversight of telehealth services," OIG says.

CMS agreed with the recommendation to monitor flagged providers but "did not explicitly indicate whether it concurred with the other four recommendations," OIG says.

Oversight Challenges

Auditors say it's likely that there is additional leakage that their audit did not detect.

“Because this data brief focuses on specific measures with very high thresholds, it does not capture all concerning billing related to telehealth services that may be occurring in Medicare," the report says.

"Additionally, this report does not confirm that any particular provider is engaging in fraudulent or abusive practices. Any determination of fraud or an overpayment would require additional investigation."

The audit also acknowledged "challenges" for oversight of Medicare "incident to" billing because it allows clinical staff services under a practitioner to be billed under the supervising practitioner's identification number.

“It is critical for program integrity efforts to identify the individual who delivered the telehealth service that is billed to Medicare," OIG says. "To address these limitations in the data, we developed measures for this report that aim to minimize the effect of "incident to" billing on the results of the claims analysis."  

ATA Responds

The American Telemedicine Association and affiliate ATA Action called the report "another clear statement outlining the resounding success of telehealth during the COVID-19 pandemic."

"Their report found that only a 'very small proportion of providers' billed Medicare inappropriately, indicating that the measures put in place to safeguard against fraud, waste, and abuse related to telehealth worked well to maintain program integrity," says Kyle Zebley, senior vice president, public policy at ATA and executive director of ATA Action. "We are incredibly proud of how telehealth was able to respond during the pandemic and extremely pleased at another very positive report from OIG."

Zebley noted that the 28 million Medicare beneficiaries who used telehealth in the first year of the pandemic "represents a dramatic increase from previous years."

"As we focus on finding ways to solve for health disparities in our country, this report sheds important light on populations that were most likely to use telehealth, including beneficiaries in urban areas, Hispanic beneficiaries, younger beneficiaries and female beneficiaries," Zebley says.