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New Areas of Fraud Emerge Due to the Expansion of Telehealth

by Jessica Hoyer Estes | Nov 16, 2023 | Legal News, Whistleblowers

New Areas of Fraud Emerge Due to the Expansion of Telehealth

What is Telehealth?

Telehealth/telemedicine allows your doctor to provide care without an in-person office visit. Telehealth is primarily done online on patients’ computers, tablets, or smartphones.

Legitimate Forms of Telehealth

  • Talking to a doctor live over the phone or video chat
  • Sending and receiving messages from a doctor using a secure messaging system
  • Using remote monitoring so a doctor can check on a patient at home and/or gather vital signs or other information to help a doctor stay informed of a patient’s progress
  • All of the above can be billed to government healthcare programs

Expansion of Telehealth Due to COVID

Medicare-reimbursable telehealth services were relatively limited prior to the COVID pandemic. CMS relaxed the requirements for reimbursement in March 2020 (LINK) due to the pandemic, and, as a result, the use of telehealth services soared. CMS reported that in April 2020, nearly half (43.5% or 1.28 million/week) of Medicare primary care visits were conducted via telehealth, compared to just 0.1% in February 2020. There are signs that patients and providers have little interest in returning to the pre-COVID status quo, as the global telehealth market (valued at $24.9 billion in 2016) is predicted to reach a value of $113 billion by 2025.

CMS Relaxed Telehealth Rules

CMS relaxed some rules around telehealth during the pandemic in order to make it easier for patients to access care. While the changes helped many patients and healthcare providers, the rule changes also made it easier for bad actors to defraud Medicare.

Some of the CMS changes involved:

  • Adding more telehealth billing codes, which allowed patients to consult with doctors remotely for a wide range of medical issues, including flu symptoms, muscle aches, etc.
  • Easing licensing requirements for doctors practicing telehealth across state lines
  • Easing restrictions on opioid prescriptions via telehealth
  • Allowing telemedicine providers to waive patient deductibles and copayments during COVID

Potential Medicare Fraud Schemes

Telehealth fraud has always existed, but it was limited given the small amount of telehealth performed and billed to the government. The expansion of telehealth, along with the increase in government payments, has brought about more widespread and brazen fraud.

Some of the most common types of telehealth fraud include:

  • Upcoding Time and Complexity of Services
    • CMS recently stated that it will closely monitor reimbursement requests to detect instances wherein providers inflate the time spent rendering telehealth services. Failure to bill accurately for the precise time spent on services and the complexity of the services in order to increase reimbursements could result in False Claims Act liability.
  • Misrepresenting the Services Provided
    • Medicare now reimburses for several types of virtual interactions, including telemedicine visits, virtual check-ins, telephone visits, and e-visits. It is critical that providers understand the requirements of each type of interaction, which CPT codes properly apply, and how to bill correctly for each CPT code.
  • Billing for Services not Rendered
    • Submitting claims for services not provided, or not effectively provided, poses a significant enforcement risk. Even if a provider attempts to provide services in good faith but technical difficulties prevent him or her from doing so, services should not be billed. Likewise, if a telehealth appointment occurs, but the patient cannot fully see, hear, or otherwise benefit from the appointment, the services could be considered ineffective and billing for those services could open up a provider to FCA liability.
  • Billing for Medically Unnecessary Prescriptions
    • One of the most common types of healthcare fraud to emerge through telehealth occurs when telemarketing companies work with sham telemedicine companies that find doctors who are willing to be paid to write medically unnecessary prescriptions for Medicare beneficiaries without speaking to the beneficiaries or evaluating their conditions. This happens frequently with opioids and durable medical equipment, such as neck and back braces.

Telehealth is expected to continue on a large scale. Meanwhile, the Office of Inspector General, the Department of Justice, and whistleblowers will continue to pursue fraud in this area.

If you believe you have information regarding fraud stemming from the COVID pandemic, please contact Hoyer Law Group.

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