The Department of Health and Human Services, Office of the Inspector General (OIG), recently released conducted an audit of Medicare claims from Telehealth Service Providers during the first year of the pandemic. The group reports that of the 742,000 providers who filed claims for telehealth services, only 1,714 posed a high risk of fraudulent claims to Medicare, including some that led to overpayments.
Although this is a low percentage of providers, those flagged as high risk were responsible for claims for over 500,000 beneficiaries totaling over $127 million in Medicare fee-for-service payments.
What qualifies as a telehealth service?
For the purposes of this audit, any remote service using technology between the patient and provider qualified as a telehealth service. Examples included office visits and nursing home visits.
What does the OIG consider “high risk” when it comes to telehealth service providers?
A a high-risk provider was one who had met at least 1 of 7 measures the auditors used to flag potential fraud, waste, or abuse of telehealth services. Examples of the measures used by auditors include billing the government for both a telehealth and facility fee, using the most expensive level every time, and billing a high number of average hours for telehealth services per visit.
What does the OIG recommend?
The OIG is calling for a strong response from the government to collect overpayments and go after those who defraud the government. This includes a call to increase monitoring efforts and follow up with those providers flagged during this audit.
As a result, providers throughout the country could find themselves the subject of allegations of a Medicare overpayment and be put through the overpayment collection process. The government could claim the provider wrongly received payment as a result of incorrect coding, insufficient documentation, or a lack of medical necessity and attempt to recoup the funds.
Providers who find themselves in this situation have options. One is to use the appeals process to fight back against this overpayment determination.
Attorney John Rivas is responsible for this communication
