Analyzing Telehealth Claims for Program Integrity Dangers

On April 20, 2023, the U.S. Division of Well being and Human Companies Workplace of Inspector Normal (“OIG”) revealed a brand new toolkit  titled “Analyzing Telehealth Claims to Assess Program Integrity Dangers” designed to investigate claims information 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 Items, and different Federal healthcare companies to establish suppliers whose billing practices might current a excessive danger and warrant additional evaluate.  

The Toolkit lists the steps for analyzing telehealth claims and identifies program integrity measures to use to telehealth claims information.  Though the Toolkit is geared towards payors and enforcement companies, healthcare suppliers ought to contemplate the steering contained within the Toolkit whereas creating insurance policies on billing for telehealth providers and incorporate the steering into their inner compliance actions.

A quick 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”) fee and protection insurance policies relevant through the first yr of the COVID-19 pandemic, as an preliminary step of the claims evaluation you will need to affirm the present relevant fee and protection insurance policies for telehealth providers. 
   
2. Accumulate claims information.  The second step is to gather the telehealth claims information. The Toolkit focuses on the providers which may be offered 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 is just not supposed for use in reference to claims information from establishments, similar to hospitals and nursing properties, and as a substitute must be used for claims information 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 rely upon the info beneath evaluate, the Toolkit emphasizes checking for unbelievable values and excluding claims with beneficiary identification numbers equal to zero. 
   
4. Analyze information 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 evaluate the info to establish potential program integrity dangers. As a result of the OIG used Medicare information 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 end result 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 is just not by itself proof of fraud and abuse. Moderately, as soon as a priority is recognized, additional investigation can be vital to find out the extent of any potential non-compliance.

Program Integrity Measures

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

1. Billing telehealth providers on the highest, costliest degree for a excessive proportion of providers. The brink for this measure might differ relying on the aim of the evaluate ( e.g., a decrease threshold for setting safeguards and figuring out dangers or a better 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 mean 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,” similar to situations 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 yr. The OIG considers a supplier billing telehealth providers on greater than 300 days per yr 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 yr 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 info in key fields (e.g., rendering supplier, billing supplier, affected person, date of service, and process code) is similar.  
   
6. Billing for a telehealth service after which ordering medical tools for a excessive proportion 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 no less than 50% of their beneficiaries, which the OIG acknowledges is much greater than the median (3%). 
   
7. Billing for each a telehealth service and a facility payment for many visits.  “Facility charges” or “originating website facility charges” are charged in reference to telehealth providers when a well being care facility hosts the affected person (e.g., gives the room and gadget) for a telehealth service, and the supplier interacting with the affected person through 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 payment for greater than 75% of their telehealth visits. 

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