OIG: Medicare Billed for Millions in Noncompliant Telehealth Claims

Ryan Black

The vast majority of incidents involved the program being billed for a telehealth encounter that did not originate in a rural location.

In a new Office of the Inspector General (OIG) report, 31 of 100 telehealth claims reviewed did not meet Medicare billing requirements. OIG estimated that such payments cost the program $3.7 million between 2014 and 2015.

Those 100 cases were a random sampling of the 19,118 telehealth claims found for that time period. The OIG wrote that it ran the report “to determine whether the Centers for Medicare & Medicaid Services (CMS) paid practitioners for telehealth services that met Medicare requirements,” noting that Medicare’s telehealth spending had ballooned from about $61,000 in 2001 to more than $17 million in 2015 (a number that has continued to rise since). But there are relatively stringent laws surrounding telehealth, and what CMS can reimburse for it.

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For instance, the law has only allowed patients in rural areas to receive reimbursement for telehealth care, and the majority (24 of 31) of the unallowable claims should have been denied “because the beneficiaries received services at nonrural originating sites.” Some of the claims had multiple problems that should have disqualified them—the report lists 38 violations for 31 incidents. Ineligible institutional providers (7 cases), unauthorized originating sites (3 cases), unallowable means of communication (2 cases), and non-covered service or service by a physician outside the United States (1 case each) rounded out the findings.

The OIG recommends the CMS conduct periodic post-payment reviews to disallow improper payments and offer better education to providers about what telehealth services are covered by Medicare.

Of course, many of those requirements might be changing. The Bipartisan Budget Act of 2018, passed by Congress in February, contained most of the language of a previously-introduced bill called the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017. That legislation calls for significant expansions of Medicare telehealth reimbursement.

The new policy will allow patients who suffer stroke to receive reimbursable telehealth counseling regardless of whether they’re in a rural area or not. Those on Medicare Advantage plans will also be eligible for additional telehealth benefits, although those have yet to be clarified: CMS will have to open a comment period before November 30th, 2018, to determine what will qualify.

Responding to the OIG report in an attached letter, CMS Administrator Seema Verma wrote that, “CMS is committed to strengthening access to care, specifically for those living in rural areas, while protecting taxpayer dollars by preventing improper payments.” She wrote that her agency concurs with all of OIG’s recommendations and will continue to work towards implementing them.

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