Analyzing Telehealth Claims for Program Integrity Dangers

On April 20, 2023, the U.S. Division of Well being and Human Providers Workplace of Inspector Normal (“OIG”) printed a brand new toolkit  titled “Analyzing Telehealth Claims to Assess Program Integrity Dangers” designed to investigate claims knowledge for telehealth providers and establish program integrity dangers to Federal healthcare applications (“Toolkit”).  

The Toolkit seems to be pushed by the OIG’s considerations concerning the elevated danger of fraud, waste, and abuse in reference to the current explosion of telehealth utilization.  The Toolkit is meant for use by private and non-private events, together with Medicare Benefit plan sponsors, personal well being plans, State Medicaid Fraud Management Models, and different Federal healthcare businesses to establish suppliers whose billing practices might current a excessive danger and warrant additional overview.  

The Toolkit lists the steps for analyzing telehealth claims and identifies program integrity measures to use to telehealth claims knowledge.  Though the Toolkit is geared towards payors and enforcement businesses, healthcare suppliers ought to think about the steerage contained within the Toolkit whereas creating insurance policies on billing for telehealth providers and incorporate the steerage into their inside compliance actions.

A short synopsis of the steps for analyzing telehealth claims and this system integrity measures outlined within the Toolkit is beneath: 

Steps for Analyzing Telehealth Claims

1. Evaluate program insurance policies.  For the reason that Toolkit relies on Medicare fee-for-service (“FFS”) cost and protection insurance policies relevant throughout the first 12 months of the COVID-19 pandemic, as an preliminary step of the claims evaluation you will need to verify the present relevant cost and protection insurance policies for telehealth providers. 
   
2. Gather claims knowledge.  The second step is to gather the telehealth claims knowledge. The Toolkit focuses on the providers that could be supplied to Medicare beneficiaries through telehealth, in addition to sure digital care providers not designated by CMS as telehealth providers, together with e-visits, digital check-ins and distant monitoring. The OIG cautions that the Toolkit will not be meant for use in reference to claims knowledge from establishments, equivalent to hospitals and nursing houses, and as a substitute must be used for claims knowledge for physicians and non-physician practitioners. 
   
3. Conduct high quality assurance checks.  The Toolkit recommends conducting high quality assurance checks on the info being analyzed.  Whereas the standard assurance strategies will depend upon the info underneath overview, the Toolkit emphasizes checking for inconceivable values and excluding claims with beneficiary identification numbers equal to zero. 
   
4. Analyze knowledge to establish program integrity dangers.  As soon as the info is gathered and checked for high quality, customers ought to carry out an evaluation to overview the info to establish potential program integrity dangers. As a result of the OIG used Medicare knowledge to develop its program integrity measures, customers might discover it vital to regulate the thresholds summarized within the Toolkit to establish suppliers whose billing practices pose danger in numerous applications. 
   
5. Interpret the outcomes of the evaluation.  As soon as the info evaluation is accomplished, customers can use the Toolkit to benchmark the outcomes towards these flagged by the OIG as potential threats to program integrity. This step might outcome within the identification of overpayments or the necessity to reevaluate how a supplier payments for telehealth providers. The OIG famous although that merely exceeding a possible threshold famous within the Toolkit will not be by itself proof of fraud and abuse. Somewhat, as soon as a priority is recognized, additional investigation could be vital to find out the extent of any potential non-compliance.

Program Integrity Measures

As soon as the telehealth claims knowledge has been analyzed, the Toolkit identifies program integrity measures to assist a corporation decide whether or not the info represents a program integrity danger. These measures embrace the next:

1. Billing telehealth providers on the highest, most costly degree for a excessive proportion of providers. The brink for this measure might range relying on the aim of the overview ( e.g., a decrease threshold for setting safeguards and figuring out dangers or the next threshold to establish particular suppliers for additional investigation).  For reference, the OIG thought of suppliers to be “excessive danger” on this measure in the event that they billed 100% of their telehealth providers on the highest degree, which the OIG acknowledges is a conservative threshold. 
   
2. Billing a excessive common variety of hours of telehealth providers per go to, which can point out billing for pointless providers or providers not rendered.  Usually, the OIG considers billing a median of greater than 2 hours of telehealth providers per go to to qualify as “excessive danger.”  The Toolkit additionally highlights checking for the so-called “unattainable day,” equivalent to cases the place suppliers billed for 25 hours of providers in a single day.  
   
3. Billing telehealth providers for a excessive variety of days in a 12 months. The OIG considers a supplier billing telehealth providers on greater than 300 days per 12 months to be “excessive danger,” because the median is 26 days for all suppliers who billed Medicare for telehealth providers. 
   
4. Billing telehealth providers for a excessive variety of sufferers. The OIG considers suppliers who billed telehealth providers for two,000 or extra beneficiaries per 12 months to be “excessive danger,” because the median is 21 beneficiaries for all suppliers who billed Medicare for telehealth providers. 
   
5. Billing a number of plans or applications for a similar telehealth service for a excessive proportion of providers.  The OIG considers suppliers to be “excessive danger” in the event that they invoice each Medicare FFS and Medicare Benefit plans for a similar service for greater than 20% of their providers.  To establish these duplicate claims, establish telehealth providers for which data in key fields (e.g., rendering supplier, billing supplier, affected person, date of service, and process code) is an identical.  
   
6. Billing for a telehealth service after which ordering medical gear for a excessive share of sufferers. The OIG considers suppliers to be “excessive danger” in the event that they billed a telehealth service after which ordered DMEPOS inside 3 months for at the least 50% of their beneficiaries, which the OIG acknowledges is way increased than the median (3%). 
   
7. Billing for each a telehealth service and a facility charge for many visits.  “Facility charges” or “originating web site facility charges” are charged in reference to telehealth providers when a well being care facility hosts the affected person (e.g., offers the room and gadget) for a telehealth service, and the supplier interacting with the affected person throughout the telehealth service is positioned elsewhere.  The OIG considers a supplier to be “excessive danger” in the event that they invoice Medicare for each the telehealth service and the power charge for greater than 75% of their telehealth visits. 

When you have any questions concerning the Toolkit or conducting an inside compliance overview of telehealth claims, please contact Milada Goturi or Kevin Kifer.