Healthcare professionals and consumers alike have embraced telehealth during the COVID-19 crisis and, in doing so, confirmed what advocates have been saying for years — that telehealth promotes greater access to care, especially for those living in areas with limited healthcare resources. During the pandemic, telehealth has enabled continuity of care, protected vulnerable individuals from exposure to the coronavirus and helped to preserve healthcare capacity and resources amid a period of unprecedented demand.
Perhaps unsurprisingly, emerging evidence suggests that telehealth is here to stay. In a recent survey from the data security firm CynergisTek, 70% of consumers said they plan to continue using virtual care visits post-pandemic. Bain & Company research found that more than 80% of providers will continue to use telehealth as much or more than they do now.
Meanwhile, the Federal Government has proposed to make permanent many of the regulatory changes meant to increase telehealth usage during the public health emergency. The administration also recently announced the further expansion of telehealth for beneficiaries of Medicare, Medicaid and the Children’s Health Insurance Program.
With Greater Access Comes Greater Risk
While ultimately good news for stakeholders across the healthcare spectrum, the sudden and exponential growth of telehealth, combined with the regulatory accommodations to facilitate its widespread adoption, could also mean good news for unscrupulous characters — i.e., fraudsters. Telehealth has historically been ripe for fraud, waste and abuse, with some of the largest healthcare fraud schemes in history involving telehealth providers.
For healthcare organizations and, specifically, special investigation units (SIUs) tasked with combatting fraud and abuse, the shift to telehealth adds new layers of complexity to an already tumultuous situation. With providers struggling to meet fluctuating demand amid unprecedented revenue shortfalls, improper billing practices — both intentional and inadvertent — are, to some degree, inevitable. Factor in hundreds of new telehealth codes and coding considerations as well as the overall stress on the healthcare system, and it is clear we must examine existing risk mitigation measures through a new, post-pandemic lens.
Mitigating Fraud & Abuse in Telehealth: 3 Strategies for SIUs
Fortunately, there are strategies that are helping healthcare organizations successfully navigate this new territory today, while strengthening the integrity of their operations for the new — more virtual — healthcare normal.
1. Investigation Planning: Charting the Course
Data visualization is a key component of an effective fraud investigation. Charts and graphs provide a clear representation of trends and outliers, including connections that could indicate a kickback or collusion scheme. Critical to the success of these tools, however, is the quality of the data that underlies them. Collecting sample data based on the appropriate modifiers — e.g., modifier 95 rather than place of service, in the case of telehealth — and conducting thorough background research provides an accurate portrayal of events from which SIUs can clearly identify and pursue potential fraud schemes.
2. Qualitative Research: Capturing Fraud at the Source
With the proper clinical context, conducting interviews with patients can validate whether services were in fact rendered as billed. For instance, a provider may bill for audio-only services as if they were delivered in an audio-visual capacity, resulting in an unjustifiably higher reimbursement rate. Similarly, using data visualization techniques to identify suspect trends, such as blanket billing or an implausibly high volume of services during a known low-demand period, can inform pointed questions for patients, such as:
- Do you have audio-video technology, such as an iPad?
- During your appointment(s), did you speak with your provider on camera?
- Did you receive care via telehealth on the dates listed?
- Did you experience a gap in treatment during the public health emergency?
- Did you request the medical equipment or drug you received? How was it offered to you?
3. Exercising Discretion: If Something Doesn’t Seem Right…
Take a closer look. As we traverse this unprecedented territory, being on high alert for potential indicators of fraud and abuse is critical to protecting healthcare consumers, organizations and the system as a whole. If something doesn’t make sense, whether clinically or in the context of the larger healthcare landscape, it is worth investigating further. Understanding the limitations of telehealth and other key considerations surrounding its use will help to ensure we are maximizing the benefits of these services while mitigating their inherent risks.
Today, more than ever, SIUs play a critical role in protecting the integrity of our healthcare system, and HMS is committed to helping healthcare organizations combat fraud in the rapidly evolving realm of telehealth.
Are you interested in learning more about how you can fight fraud, waste and abuse in healthcare's new normal?