On April 20, 2023, the U.S. Division of Well being and Human Companies Workplace of Inspector Common (“OIG”) printed a brand new toolkit titled “Analyzing Telehealth Claims to Assess Program Integrity Dangers” designed to research claims information for telehealth providers and determine program integrity dangers to Federal healthcare applications (“Toolkit”).
The Toolkit seems to be pushed by the OIG’s considerations in regards to the elevated threat 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 Items, and different Federal healthcare businesses to determine suppliers whose billing practices might current a excessive threat 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 contemplate the steering contained within the Toolkit whereas growing insurance policies on billing for telehealth providers and incorporate the steering into their inner compliance actions.
A short synopsis of the steps for analyzing telehealth claims and this system integrity measures outlined within the Toolkit is beneath:
Steps for Analyzing Telehealth Claims
- Overview program insurance policies. Because the Toolkit is predicated on Medicare fee-for-service (“FFS”) fee and protection insurance policies relevant throughout the first yr of the COVID-19 pandemic, as an preliminary step of the claims evaluation it is very important affirm the present relevant fee and protection insurance policies for telehealth providers.
- Gather claims information. The second step is to gather the telehealth claims information. The Toolkit focuses on the providers that could be offered to Medicare beneficiaries by way of telehealth, in addition to sure digital care providers not designated by CMS as telehealth providers, together with e-visits, digital check-ins and distant monitoring. The OIG cautions that the Toolkit is just not supposed for use in reference to claims information from establishments, resembling hospitals and nursing houses, and as a substitute must be used for claims information for physicians and non-physician practitioners.
- Conduct high quality assurance checks. The Toolkit recommends conducting high quality assurance checks on the info being analyzed. Whereas the standard assurance strategies will rely on the info underneath evaluation, the Toolkit emphasizes checking for inconceivable values and excluding claims with beneficiary identification numbers equal to zero.
- Analyze information to determine program integrity dangers. As soon as the info is gathered and checked for high quality, customers ought to carry out an evaluation to evaluation the info to determine potential program integrity dangers. As a result of the OIG used Medicare information to develop its program integrity measures, customers might discover it obligatory to regulate the thresholds summarized within the Toolkit to determine suppliers whose billing practices pose threat in numerous applications.
- Interpret the outcomes of the evaluation. As soon as the info evaluation is accomplished, customers can use the Toolkit to benchmark the outcomes in opposition to these flagged by the OIG as potential threats to program integrity. This step might consequence within the identification of overpayments or the necessity to reevaluate how a supplier payments for telehealth providers. The OIG famous although that merely exceeding a possible threshold famous within the Toolkit is just not by itself proof of fraud and abuse. Moderately, as soon as a priority is recognized, additional investigation can be obligatory 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 info represents a program integrity threat. These measures embrace the next:
- Billing telehealth providers on the highest, most costly degree for a excessive proportion of providers. The brink for this measure might range relying on the aim of the evaluation ( e.g., a decrease threshold for setting safeguards and figuring out dangers or a better threshold to determine particular suppliers for additional investigation). For reference, the OIG thought of suppliers to be “excessive threat” on this measure in the event that they billed 100% of their telehealth providers on the highest degree, which the OIG acknowledges is a conservative threshold.
- Billing a excessive common variety of hours of telehealth providers per go to, which can point out billing for pointless providers or providers not rendered. Usually, the OIG considers billing a median of greater than 2 hours of telehealth providers per go to to qualify as “excessive threat.” The Toolkit additionally highlights checking for the so-called “not possible day,” resembling situations the place suppliers billed for 25 hours of providers in a single day.
- Billing telehealth providers for a excessive variety of days in a yr. The OIG considers a supplier billing telehealth providers on greater than 300 days per yr to be “excessive threat,” because the median is 26 days for all suppliers who billed Medicare for telehealth providers.
- Billing telehealth providers for a excessive variety of sufferers. The OIG considers suppliers who billed telehealth providers for two,000 or extra beneficiaries per yr to be “excessive threat,” because the median is 21 beneficiaries for all suppliers who billed Medicare for telehealth providers.
- Billing a number of plans or applications for a similar telehealth service for a excessive proportion of providers. The OIG considers suppliers to be “excessive threat” in the event that they invoice each Medicare FFS and Medicare Benefit plans for a similar service for greater than 20% of their providers. To determine these duplicate claims, determine telehealth providers for which info in key fields (e.g., rendering supplier, billing supplier, affected person, date of service, and process code) is an identical.
- Billing for a telehealth service after which ordering medical tools for a excessive proportion of sufferers. The OIG considers suppliers to be “excessive threat” in the event that they billed a telehealth service after which ordered DMEPOS inside 3 months for a minimum of 50% of their beneficiaries, which the OIG acknowledges is way larger than the median (3%).
- Billing for each a telehealth service and a facility payment for many visits. “Facility charges” or “originating web site facility charges” are charged in reference to telehealth providers when a well being care facility hosts the affected person (e.g., gives 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 threat” in the event that they invoice Medicare for each the telehealth service and the power payment for greater than 75% of their telehealth visits.
If in case you have any questions in regards to the Toolkit or conducting an inner compliance evaluation of telehealth claims, please contact Milada Goturi or Kevin Kifer.
