Federal inspectors find ‘high risk’ providers in Medicare telehealth billing worth $127.7M

HHS develops new measures that could indicate fraud, abuse, or waste.

Federal inspectors flagged as “high risk” 1,714 health care providers who billed Medicare for telehealth services worth $127.7 million during the COVID-19 pandemic.

The U.S. Department of Human Services’ Office of the Inspector General (HHS-OIG) developed seven measures that could indicate fraud, waste, or abuse of telehealth services, according to a new study published this month.

The findings did not confirm particular health care providers were engaging in fraud. But “all of these providers warrant further scrutiny. For example, they may be billing for telehealth services that are not medically necessary or were never provided,” OIG said in a news release accompanying the study.

CMS will follow up on the providers identified in the report, but has not concurred with four other OIG recommendations to bolster oversight and minimize risk:

  • Strengthen monitoring and targeted oversight of telehealth services.
  • Provide additional education to providers on appropriate billing for telehealth services.
  • Improve transparency of “incident to” services to differentiate between services provided by a physician, by a nonphysician practitioner, or by directly supervised clinical staff.
  • Identify telehealth companies that bill Medicare. Currently there is not systematic way to do so in Medicare data.

The report follows the announcement this summer that federal investigators netted a record $5 billion in health care fraud judgments and settlements in the last year. About two weeks later, the U.S. Department of Justice, with HHS and the Centers for Medicare & Medicaid Services (CMS), announced new allegations of medical fraud tallying more than $1.2 billion by 36 defendants across the country.

HHS this summer published a new advisory with clues about fraud that physicians should look for when engaging in telehealth services.

Seven measures

“Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks” examined billing by about 742,000 providers from March 1, 2020, to Feb. 28, 2022. OIG acknowledged those deemed “high risk” were a small proportion of all providers, but the findings show the need for strong, targeted oversight for telehealth services.

The measures and findings included:

  • 672 providers billed for a facility fee and a telehealth service for more than 75% of telehealth visits, 148,000 visits, totaling more than $14.3 million for the visits. Providers should not bill for both for the same visit.
  • 365 providers had possible “upcoding,” billing for certain telehealth services at the highest, most expensive level every time. They may deliver higher levels of services than are medically necessary, or bill for services not provided.
  • 328 providers billed for telehealth for more than 300 days of the year, averaging to more than 25 days per month, per provider. That could indicate billing for services not provided.
  • 138 providers billed both Medicare fee-for-service and a Medicare Advantage plan for the same telehealth service, for more than 20% of telehealth services. That could indicate duplicate claims to increase Medicare payments.
  • 86 providers billed for more than two hours of telehealth services per visit, more than the median of 21 minutes of telehealth services per visit for all providers of telehealth services.
  • 76 providers billed for telehealth services for at least 2,000 beneficiaries a year, totaling 1.7 million telehealth services and nearly $57.5 million in Medicare fee-for-service payments. The figures were “far above” the median of 21 beneficiaries for all telehealth service providers, and could indicate providers billing for services not rendered or creating “serious concerns about the quality of care.”
  • 67 providers billed for telehealth services and ordered medical equipment and supplies worth $28 million for at least half their beneficiaries, more than the median of 3% for all providers.