On April 20, 2023, the U.S. Division of Well being and Human Providers Workplace of Inspector Common (“OIG”) revealed a brand new toolkit  titled “Analyzing Telehealth Claims to Assess Program Integrity Dangers” designed to investigate claims information for telehealth companies and establish program integrity dangers to Federal healthcare packages (“Toolkit”).  

The Toolkit seems to be pushed by the OIG’s considerations concerning the elevated danger 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 businesses to establish suppliers whose billing practices could current a excessive danger and warrant additional evaluation.  

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 businesses, healthcare suppliers ought to think about the steering contained within the Toolkit whereas growing insurance policies on billing for telehealth companies and incorporate the steering into their inside 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. Evaluate program insurance policies.  For the reason that Toolkit is predicated 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. Gather claims information.  The second step is to gather the telehealth claims information. The Toolkit focuses on the companies which may be offered to Medicare beneficiaries by way of 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 just isn’t supposed for use in reference to claims information from establishments, comparable to hospitals and nursing houses, and as an alternative ought 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 information being analyzed.  Whereas the standard assurance strategies will rely on the information underneath evaluation, the Toolkit emphasizes checking for inconceivable values and excluding claims with beneficiary identification numbers equal to zero. 
   
4. Analyze information to establish program integrity dangers.  As soon as the information is gathered and checked for high quality, customers ought to carry out an evaluation to evaluation the information to establish potential program integrity dangers. As a result of the OIG used Medicare information to develop its program integrity measures, customers could discover it needed to regulate the thresholds summarized within the Toolkit to establish suppliers whose billing practices pose danger in several packages. 
   
5. Interpret the outcomes of the evaluation.  As soon as the information evaluation is accomplished, customers can use the Toolkit to benchmark the outcomes towards these flagged by the OIG as potential threats to program integrity. This step could end result 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 just isn’t by itself proof of fraud and abuse. Reasonably, as soon as a priority is recognized, additional investigation can be needed 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 information represents a program integrity danger. These measures embrace the next:

1. Billing telehealth companies on the highest, most costly stage for a excessive proportion of companies. The brink for this measure could fluctuate relying on the aim of the evaluation ( 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 danger” on this measure in the event that they billed 100% of their telehealth companies on the highest stage, 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 danger.”  The Toolkit additionally highlights checking for the so-called “not possible day,” comparable 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 danger,” 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 danger,” because the median is 21 beneficiaries for all suppliers who billed Medicare for telehealth companies. 
   
5. Billing a number of plans or packages for a similar telehealth service for a excessive proportion of companies.  The OIG considers suppliers to be “excessive danger” 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 equivalent.  
   
6. Billing for a telehealth service after which ordering medical tools for a excessive proportion of sufferers. The OIG considers suppliers to be “excessive danger” in the event that they billed a telehealth service after which ordered DMEPOS inside 3 months for not less than 50% of their beneficiaries, which the OIG acknowledges is much larger 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., supplies the room and system) 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 danger” in the event that they invoice Medicare for each the telehealth service and the power charge for greater than 75% of their telehealth visits. 

If in case you have any questions concerning the Toolkit or conducting an inside compliance evaluation of telehealth claims, please contact or .