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 research claims knowledge for telehealth providers and establish program integrity dangers to Federal healthcare packages (“Toolkit”).  

The Toolkit seems to be pushed by the OIG’s considerations in regards to the elevated threat 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 threat and warrant additional assessment.  

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 companies, healthcare suppliers ought to contemplate the steering contained within the Toolkit whereas growing 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 under: 

Steps for Analyzing Telehealth Claims

1. Evaluation program insurance policies.  For the reason that Toolkit is predicated on Medicare fee-for-service (“FFS”) cost and protection insurance policies relevant throughout the first yr of the COVID-19 pandemic, as an preliminary step of the claims evaluation it is very important 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 by way of 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 isn’t supposed for use in reference to claims knowledge from establishments, reminiscent of hospitals and nursing properties, and as an alternative 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 information being analyzed.  Whereas the standard assurance strategies will depend upon the information underneath assessment, 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 information is gathered and checked for high quality, customers ought to carry out an evaluation to assessment the information 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 essential to regulate the thresholds summarized within the Toolkit to establish suppliers whose billing practices pose threat in numerous packages. 
   
5. Interpret the outcomes of the evaluation.  As soon as the information evaluation is accomplished, customers can use the Toolkit to benchmark the outcomes in opposition to 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 isn’t by itself proof of fraud and abuse. Relatively, as soon as a priority is recognized, additional investigation can be essential 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 information represents a program integrity threat. These measures embody the next:

1. Billing telehealth providers on the highest, costliest degree for a excessive proportion of providers. The edge for this measure might fluctuate relying on the aim of the assessment ( 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 threat” 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.  Typically, the OIG considers billing a mean of greater than 2 hours of telehealth providers per go to to qualify as “excessive threat.”  The Toolkit additionally highlights checking for the so-called “unattainable day,” reminiscent of 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 yr. The OIG considers a supplier billing telehealth providers on greater than 300 days per yr to be “excessive threat,” 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 threat,” because the median is 21 beneficiaries for all suppliers who billed Medicare for telehealth providers. 
   
5. Billing a number of plans or packages for a similar telehealth service for a excessive proportion of providers.  The OIG considers suppliers to be “excessive threat” 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 proportion of sufferers. The OIG considers suppliers to be “excessive threat” in the event that they billed a telehealth service after which ordered DMEPOS inside 3 months for a minimum of 50% of their beneficiaries, which the OIG acknowledges is way larger than the median (3%). 
   
7. Billing for each a telehealth service and a facility payment 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., supplies the room and system) 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 threat” in the event that they invoice Medicare for each the telehealth service and the ability payment for greater than 75% of their telehealth visits. 

When you have any questions in regards to the Toolkit or conducting an inner compliance assessment of telehealth claims, please contact Milada Goturi or Kevin Kifer.