Analyzing Telehealth Claims for Program Integrity Dangers

On April 20, 2023, the U.S. Division of Well being and Human Providers Workplace of Inspector Common (“OIG”) printed a brand new toolkit  titled “Analyzing Telehealth Claims to Assess Program Integrity Dangers” designed to investigate claims knowledge for telehealth companies and determine program integrity dangers to Federal healthcare packages (“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, non-public well being plans, State Medicaid Fraud Management Items, and different Federal healthcare companies to determine suppliers whose billing practices could 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 knowledge.  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 companies 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. Assessment program insurance policies.  For the reason that Toolkit relies on Medicare fee-for-service (“FFS”) cost and protection insurance policies relevant in the course of the first yr of the COVID-19 pandemic, as an preliminary step of the claims evaluation you will need to affirm the present relevant cost and protection insurance policies for telehealth companies. 
   
2. Acquire claims knowledge.  The second step is to gather the telehealth claims knowledge. The Toolkit focuses on the companies that could be supplied to Medicare beneficiaries by way of telehealth, in addition to sure digital care companies not designated by CMS as telehealth companies, together with e-visits, digital check-ins and distant monitoring. The OIG cautions that the Toolkit just isn’t meant for use in reference to claims knowledge from establishments, reminiscent of hospitals and nursing houses, and as an alternative ought to 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 rely upon the info underneath evaluate, the Toolkit emphasizes checking for inconceivable values and excluding claims with beneficiary identification numbers equal to zero. 
   
4. Analyze knowledge to determine 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 determine potential program integrity dangers. As a result of the OIG used Medicare knowledge to develop its program integrity measures, customers could discover it needed to regulate the thresholds summarized within the Toolkit to determine suppliers whose billing practices pose danger in numerous packages. 
   
5. Interpret the outcomes of the evaluation.  As soon as the info 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 could outcome within the identification of overpayments or the necessity to reevaluate how a supplier payments for telehealth companies. The OIG famous although that merely exceeding a possible threshold famous within the Toolkit just isn’t by itself proof of fraud and abuse. Quite, as soon as a priority is recognized, additional investigation can be needed 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 embody the next:

1. Billing telehealth companies on the highest, most costly stage for a excessive proportion of companies. The brink for this measure could fluctuate relying on the aim of the evaluate ( e.g., a decrease threshold for setting safeguards and figuring out dangers or the next threshold to determine 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 companies on the highest stage, which the OIG acknowledges is a conservative threshold. 
   
2. Billing a excessive common variety of hours of telehealth companies per go to, which can point out billing for pointless companies or companies not rendered.  Usually, the OIG considers billing a mean of greater than 2 hours of telehealth companies per go to to qualify as “excessive danger.”  The Toolkit additionally highlights checking for the so-called “unattainable day,” reminiscent of situations the place suppliers billed for 25 hours of companies in a single day.  
   
3. Billing telehealth companies for a excessive variety of days in a yr. The OIG considers a supplier billing telehealth companies 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 companies. 
   
4. Billing telehealth companies for a excessive variety of sufferers. The OIG considers suppliers who billed telehealth companies 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 companies. 
   
5. Billing a number of plans or packages for a similar telehealth service for a excessive proportion of companies.  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 companies.  To determine these duplicate claims, determine telehealth companies for which data in key fields (e.g., rendering supplier, billing supplier, affected person, date of service, and process code) is equivalent.  
   
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 at the very least 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 price for many visits.  “Facility charges” or “originating web site facility charges” are charged in reference to telehealth companies when a well being care facility hosts the affected person (e.g., gives the room and machine) for a telehealth service, and the supplier interacting with the affected person in the course of 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 price 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.