The continued use of telemedicine – made dramatically more mainstream during the pandemic – may open the door for more fraud, waste, and abuse in healthcare claims. The number of fraud cases related to healthcare “more than doubled from 2019 to 2020 and was at the highest level ever reported” according to the National Law Review.1 For employers with self-funded healthcare plans it is just the latest reason to monitor healthcare claims for fraud and waste.
The rise of telemedicine injects a whole new opportunity for unscrupulous providers to bill plans deceptively. Early on, when telemedicine came into practice, rules and regulations regarding billing were in place outlining for providers and payers the specific reasons visits could be done via telemedicine. This was especially true for Medicare. However, when the pandemic hit and regulations were relaxed out of the necessity of the situation, that eliminated many barriers for those who wanted to take advantage of the system.
Bill Young, SmartLight’s head of clinical operations who has 20 years of federal healthcare fraud investigative experience, said the types of fraud that might slip through the cracks via telemedicine are only limited by your imagination.
“More common forms of telemedicine fraud involve provider billing and coding errors, which will only increase in volume as CMS (Center for Medicare & Medicaid Services) continues to expand its list of reimbursable telehealth services,”2 according to the American Health Law Association.
“As more patient-physician interfacing occurs over telehealth platforms, CMS will closely monitor reimbursement requests from providers to monitor potential for up-coding the amount of time spent with patients and the complexity of the services rendered. There will also be opportunity for fraud in misrepresenting the virtual services provided. Different CPT codes apply depending on the type of patient-provider interaction and whether that meeting is synchronous or asynchronous. In this virtual environment, it is now much easier for a healthcare provider to fraudulently bill for the CPT code that will give him greater reimbursement or bill for a service he never rendered.”3
“I don’t know if you can put that genie back in the bottle,” Young said. “Everyone has gotten accustomed to the relaxed rules but there will have to be some effort to reinstate some of the telemedicine requirements prior to COVID because otherwise you might as well just open the bank vault.”
In terms of examining healthcare claims data, employers were not equipped to monitor employee healthcare claims before telemedicine and other digital healthcare trends arose. They are no closer to doing so now.
“It just throws another wrench into the system and gives employers all the more reason to scrutinize their healthcare claims data. Telemedicine has just injected a whole new opportunity for unscrupulous providers to bill these employers and if you’re not watching the store the money is just going to go out the door,” Young said.
And while we are seeing telemedicine numbers drop– a reported 12.5% drop in April 2021 – the use of it will not go away.4 A bill was introduced in Congress last month to permanently extend telemedicine waivers issued during the pandemic.5 This bill, according to mHealth Intelligence, “tackles some of the most noteworthy waivers introduced by the Centers for Medicare & Medicaid Services over the past year and a half to expand telehealth coverage and access during the coronavirus pandemic … to make sure those freedoms continue after the public health emergency has ended. … The bill would allow the Health and Human Services Secretary to expand the list of healthcare providers able to use telehealth, and it would clarify fraud and abuse laws to give providers more leeway to use telehealth and remote patient monitoring platforms.” 6
There is a place for telemedicine in the healthcare system but as we move forward technology will continue to give rise to different ways of delivering healthcare. In fact, we’re already seeing situations such as texting with online telemedicine companies opening access to healthcare. But all these situations also open the door for fraud, waste, and abuse in a unique way that we haven’t seen before. For employers, that means continually trying to keep up.
1. Breen, George B., Sibley, Erica F., and Harris, Elizabeth A., “DOJ False Claims Act Statistics 2020: Over 80% of all Recoveries Came from the Health Care industry,” National Law Review, Jan. 21, 2021, https://www.natlawreview.com/article/doj-false-claims-act-statistics-2020-over-80-all-recoveries-came-health-care
2. Sitton, Matthew, “Telemedicine Fraud During the Pandemic and Beyond,” American Health Law Association Jan. 12, 2021.
3 Giancola, Paul and Stedman, Claudia, “Telehealth Fraud Triggered by COVID-19 Pandemic,” JDSupr, Feb. 16, 2021, https://www.jdsupra.com/legalnews/telehealth-fraud-triggered-by-covid-19-8657616/
4. Devereau, Mari, “Telehealth use falls for third straight month, in-person appointments increase,” Modern Healthcare, July 7, 2021. https://www.modernhealthcare.com/technology/telehealth-use-falls-third-straight-month-person-appointments-increase?utm_source=modern-healthcare-covid-19-coverage&utm_medium=email&utm_campaign=20210708&utm_content=article3-headline
5. “Cheney and Dingell Introduce Bipartisan Legislation To Allow Americans To Take Advantage of Telehealth Services,” June 22, 2021. https://cheney.house.gov/2021/06/22/cheney-dingell-introduce-bipartisan-legislation-to-allow-americans-to-take-advantage-of-telehealth-services/
6. Wicklund, Eric, “Cheney, Dingell Launch Bipartisan Effort to Codify COVID-19 Telehealth Waivers,” mHealth Intelligence, June 22, 2021. https://mhealthintelligence.com/news/cheney-dingell-launch-bipartisan-effort-to-codify-covid-19-telehealth-waivers