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The pandemic-induced telehealth
revolution expanded access to an exciting new modality of care delivery, but
a new report from federal watchdogs across six Offices of Inspectors
General (OIGs) found that federal payers face new, telehealth-derived
challenges in stopping waste, fraud and abuse. Those findings mean the
commercial carriers that administer certain federally underwritten health
insurance plans have a new auditing and accountability challenge as
telehealth settles in as a permanent part of the care delivery
landscape.
Telehealth billing fraud
has emerged
- Katherine
Hempstead, Ph.D., senior policy adviser at the Robert Wood Johnson Foundation,
tells AIS Health that the report identified practices that unethical
providers may have adapted from older fraud tactics.
- “Concerns about
bad incentives and/or fraud are one of the reasons that there has been a
lot of debate about telehealth payment policy. It is another channel to
provide services, which is great in one way, but also can be conducive
to new ways to improperly represent the provision of services through
fraud or miscoding,” Hempstead says.
- Despite the
success of telehealth — or perhaps because of it — the report
“identified risks involving inappropriate billing for the highest, most
expensive level of telehealth services.” In one striking example, “the
HHS OIG identified more than 300 Medicare providers who billed for
telehealth services at the highest, most expensive level every time,
totaling approximately $5.2 million.”
- Some providers
also attempted to charge telehealth claims to federal insurance programs
for in-person services such as debridement, anesthesia and acupuncture.
The OIGs wrote that “these examples raise concern, as they may indicate
that to inappropriately maximize their payments for each visit,
providers are billing for services that are not being provided
appropriately or billing for telehealth services that never
occurred.”
Capitation may protect MA
plans from some fraud
- Unethical
providers also attempted to charge Medicare Advantage plans, the report
found: “The HHS OIG identified 138 providers who repeatedly billed both
Medicare fee-for-service and a Medicare Advantage plan for the same
telehealth service.”
- With those
sorts of findings, Michael Bagel, director of public policy at the Alliance
of Community Health Plans (ACHP), says that there is plenty MA plans can
learn from the report. But he also believes that MA plans are more
insulated from fraudulent billing than fee-for-service Medicare because
most of their providers work under capitated reimbursement, an
arrangement that calls for a closer relationship between plan and
provider.
- Bagel suggests
that providers with capitation or risk-based network agreements work
with the plan in “looking at, ‘What does the whole benefit of this patient
look like?’ Especially with a preventative benefit, our incentives for
how we’re utilizing the [telehealth] benefits are just different than in
fee-for-service.”
- Bagel also adds
that “when fee-for-service [flags] problems, and especially identifies
providers who are bad actors and shares that information — we can know
that, so that we don’t contract with those potentially fraudulent
providers.”
- Hempstead says
that argument makes some sense, but she observes that capitation can’t
solve every problem. “To the extent that MA plans are more likely to be
in some kind of APM [Alternative Payment Model] or capitation
relationship with their providers, there may be fewer incentives for
upcoding or inappropriate billing,” she says.
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