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”) printed a brand new toolkit  titled “Analyzing Telehealth Claims to Assess Program Integrity Dangers” designed to research claims information for telehealth companies and establish program integrity dangers to Federal healthcare applications (“Toolkit”).  

The Toolkit seems to be pushed by the OIG’s issues concerning the elevated threat of fraud, waste, and abuse in reference to the latest 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 Models, and different Federal healthcare companies to establish suppliers whose billing practices might current a excessive threat 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 steerage contained within the Toolkit whereas growing insurance policies on billing for telehealth companies and incorporate the steerage 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. Evaluation program insurance policies.  Because the Toolkit relies on Medicare fee-for-service (“FFS”) fee 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 affirm the present relevant fee and protection insurance policies for telehealth companies. 
   
2. Acquire claims information.  The second step is to gather the telehealth claims information. The Toolkit focuses on the companies which may be supplied to Medicare beneficiaries through 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 isn’t meant for use in reference to claims information from establishments, similar to hospitals and nursing houses, and as an alternative needs to 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 on the info underneath 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 threat in several 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 in opposition to these flagged by the OIG as potential threats to program integrity. This step might consequence 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 isn’t by itself proof of fraud and abuse. Reasonably, 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 information has been analyzed, the Toolkit identifies program integrity measures to assist a corporation decide whether or not the info represents a program integrity threat. These measures embrace the next:

1. Billing telehealth companies on the highest, costliest degree for a excessive proportion of companies. The brink for this measure might range 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-about suppliers to be “excessive threat” on this measure in the event that they billed 100% of their telehealth companies on the highest degree, 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 threat.”  The Toolkit additionally highlights checking for the so-called “not possible day,” similar to cases 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 12 months. The OIG considers a supplier billing telehealth companies on greater than 300 days per 12 months to be “excessive threat,” 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 12 months to be “excessive threat,” because the median is 21 beneficiaries for all suppliers who billed Medicare for telehealth companies. 
   
5. Billing a number of plans or applications for a similar telehealth service for a excessive proportion of companies.  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 companies.  To establish these duplicate claims, establish telehealth companies for which data 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 share 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 no less than 50% of their beneficiaries, which the OIG acknowledges is much increased than the median (3%). 
   
7. Billing for each a telehealth service and a facility charge for many visits.  “Facility charges” or “originating website facility charges” are charged in reference to telehealth companies when a well being care facility hosts the affected person (e.g., offers the room and machine) for a telehealth service, and the supplier interacting with the affected person throughout the telehealth service is situated 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 charge 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.