OIG: Certain telehealth billing practices are a high risk to Medicare

Wednesday, September 28, 2022

The Office of Inspector General (OIG) recently released an audit report on Medicare integrity risks related to billing for telehealth services during the first year of the COVID-19 pandemic. Although the OIG identified only a small portion of high-risk providers, it acknowledged the need for additional oversight as telehealth continues to grow in popularity.

Out of the 724,000 sampled providers who billed for a telehealth service from March 2020 to February 2021, 1,714 were identified as a high risk to Medicare by the OIG. These providers received $127.7 million in Medicare fee-for-service payments and billed for telehealth services for almost 500,000 beneficiaries.

Each of these high-risk providers “had concerning billing on at least one of seven measures that may indicate fraud, waste, or abuse,” said the report.

The seven measures used by the OIG are as follows:

  • Billing both a telehealth service and a facility fee for most visits
  • Billing telehealth services at the highest, most expensive level every time
  • Billing telehealth services for a high number of days in a year
  • Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services
  • Billing a high average number of hours of telehealth services per visit
  • Billing telehealth services for a high number of beneficiaries
  • Billing for a telehealth service and ordering medical equipment for a high proportion of beneficiaries

The OIG determined 672 of the high-risk providers billed for both a facility fee—also known as an originating site fee—and a telehealth service fee for 75% of their telehealth visits. “Billing for both would mean that the provider and beneficiary were at the same physical location when the telehealth service was provided; therefore, the provider is not allowed to deliver a telehealth service,” according to the report. If a beneficiary receives telehealth services in a facility, such as a physician’s office or hospital, separate from the physician’s location, only the facility where the service occurred can charge Medicare an originating site fee.

In addition, it discovered over half of the high-risk providers “are a part of a medical practice with at least one other provider whose billing poses a high risk to Medicare.”

The OIG provided CMS with five recommendations to minimize risks, but the agency only explicitly concurred to “follow up as appropriate” with the providers identified in the report.

Revenue integrity professionals should ensure their organization’s telehealth billing practices are appropriate. Conduct audits of telehealth claims, particularly those from 2020 when numerous guideline changes and waivers were released. Address any errors identified as appropriate including returning overpayments and providing education. Telehealth is still finding its footing, so it’s important to regularly check for updates to CMS guidelines.

Editor’s note: Find more NAHRI resources on telehealth here.