How to Mitigate Telehealth Risks and Create an Action Plan

The OIG issued a report in 2018 which revealed an error rate of 31% in billing and coding for telehealth services. Why is this important if it was in 2018? It’s important because it emphasizes that telehealth services were already on the radar of the OIG, and that was before telehealth services exploded and all of the guidelines started changing. Since the Public Health Emergency (PHE) was declared, telehealth usage accounts for 5.7 to 13% of private health insurance claims, which doesn’t even include Medicare and Medicaid.

Between the summer and fall of 2020, 1 out of 4 Medicare beneficiaries had a telehealth visit.

OIG has eight different telehealth audits currently on its work plan. This section will talk about the OIG audits in more detail.

The OIG Timeline Of Telehealth Activities

In June of 2020

Medicaid—Telehealth Expansion During COVID-19 Emergency

Our objective is to determine whether State agencies and providers complied with Federal and State requirements for telehealth services under the national emergency declaration and whether the States gave providers adequate guidance on telehealth requirements.

In October 2020

Use of Medicare Telehealth Services During the COVID-19 Pandemic

CMS allowed Medicare beneficiaries to access a broader range of telehealth services without traveling to a healthcare facility in response to the pandemic. CMS is proposing to make some of these changes permanent. This review will be based on Medicare Parts B and C data and will look at the use of telehealth services in Medicare during the COVID-19 pandemic. It will look at the extent to which Medicare beneficiaries are using telehealth services, how these services compare to the use of the same services delivered in-person, and the different types of providers and beneficiaries using telehealth services.

Medicare Telehealth Services During the COVID-19 Pandemic: Program Integrity Risks

In response to the COVID-19 pandemic, CMS implemented several waivers and flexibilities that allowed Medicare beneficiaries to access a broader range of telehealth services without traveling to a healthcare facility. This review will be based on Medicare Parts B and C data and identify program integrity risks associated with Medicare telehealth services during the pandemic. OIG will analyze providers’ billing patterns for telehealth services. We will also describe key characteristics of providers that may pose a program integrity risk to the Medicare program.

In January 2021

Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency

CMS is exploring how to expand telehealth services beyond the PHE to provide care for Medicare beneficiaries. They will conduct a series of audits of Medicare Part B telehealth services in two phases. Phase one audits will focus on assessing whether services such as evaluation and management, opioid use disorder, end-stage renal disease, and psychotherapy (Work Plan number W-00-21-35801) meet Medicare requirements. Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.

In February of 2021

Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency

We will evaluate home health services provided by agencies during the COVID-19 public health emergency to determine which types of skilled services were furnished via telehealth and whether those services were administered and billed following Medicare requirements. Any services that were improperly billed will be reported as overpayments. We will make appropriate recommendations to CMS based on the results of our review.

In June of 2021

Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care

This review will describe: (1) the challenges that States face using telehealth to provide behavioral health services to Medicaid enrollees and (2) the extent to which States assess the effects of telehealth on access, cost, and quality and monitor telehealth to provide behavioral health services. We collected data for these products before States’ expanding telehealth in response to the COVID-19 pandemic; however, this information continues to be valuable in future decisions to strengthen telehealth on a more permanent basis.

In August of 2021

Data Snapshot: Review of Beneficiaries’ Relationships With Providers for Telehealth Services

This data snapshot will describe how Medicare beneficiaries had established relationships with providers from whom they received telehealth services. We will also look for any differences in these relationships between traditional Medicare and Medicare Advantage and among the different types of telehealth services.

Mitigating Risk

CMS issued Comparative Billing report 202108 in August of 2021, which analyzed the impact of the PHE on Telehealth. This report aimed to educate providers and increase awareness of telehealth services during the PHE and reference different guidelines for billing professional telehealth services during the PHE. Your organization may have received your CBR with this information. This report is a handy tool in your annual compliance plan.

CMS defines a CBR as an educational resource and tool used for improvement. A report that compares providers on a state, specialty, or even national level and summarizes Medicare claim data statistics for areas that may be at risk for improper Medicare payment. Primarily, whether the claim was correctly coded and billed and whether the treatment provided to the patient was necessary and in line with Medicare payment policy. A CBR doesn’t’ identify incorrect payments, but it can alert if billing statistics look unusual compared to their peers.

This report analyzed all 2020 DOS, 99201-99215 with POS 11 and Mod 95.

You would have access to or receive this report if you are in the top 25% of providers by claims volume within the top 25 specialties who submitted qualifying services. If you have a much higher incidence of claims than peers, this is an excellent opportunity to self-audit and look at correct claims submission and documentation.

Stay Updated, Evaluate Workflow, and Make Adjustments

In summary, task someone in your company to keep up with changes to telehealth guidelines for all payers and make sure to disseminate that information. Evaluate your current workflow, understand what is working and what isn’t, and understand how that workflow affects the revenue cycle. Make adjustments wherever it’s necessary now. There are plenty of good resources available through the Dept of Health and Human Services, American Medical Association, MGMA, etc. Those resources can help guide you and offer solutions for tools you can implement in your workflow and help you manage your revenue cycle concerning telehealth services.

Most importantly, do your research so you fully understand your risk. If you have been notified of a comparative billing report and haven’t looked at it, I strongly encourage you to do so. Also, whether you audit internally or outsource audits to an organization, your organization should conduct audits of telehealth services against all of your payor guidelines. If the OIG focuses heavily on telehealth, that will allow inevitable push downstream to other payors.

Finally, depending on your research and audits, make an action plan to address any issues. If you find you have been misapplying the guidelines, then make a plan for self-reporting to payors and manage documentation and billing gaps. That may mean adjustments to provider templates and further training for providers and staff.


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