How SIUs Are Using Pattern & Outlier Detection to Combat Telehealth Fraud

December 14, 2020 Health Ideas Staff

The National Health Care Anti-Fraud Association (NHCAA) estimates healthcare fraud to be responsible for up to $300 billion in losses each year — and that was before a global pandemic wreaked havoc on the nation’s healthcare system and economy.

For special investigation units (SIUs), detecting and combatting fraud was hard enough in a pre-pandemic world; factor in the sudden explosion of telehealth and fluctuating regulatory environment to support it, and it is clear SIUs have their work cut out for them. Fortunately, there are tools to make it easier — namely, data visualization techniques that enable SIUs to clearly identify patterns and outliers that could be indicative of fraud and abuse.

Of course, charts and graphs are only as effective as the quality of the data that underlies them. To help you get the most out of yours, we are highlighting several best practices to provide SIUs with a clear-cut mechanism for identifying and combatting fraud and abuse in the expanding realm of telehealth.

1. Dive Deep

Oftentimes, we find that the individuals involved in a fraud scheme have a history of criminal behavior, such as accepting bribes or similarly unscrupulous activities. Conducting thorough background research encompassing criminal and civil litigation records is critical to identifying ownership connections that could indicate a kickback or collusion scheme. Additionally, speaking with clinical experts as part of your research can help to determine whether an event — or series of events — makes sense in a clinical context.

2. Sample Wisely

The quality of your sample data is perhaps the most important consideration in your investigation planning, as this provides the basis for your ultimate record review. When investigating telehealth fraud during the PHE, for instance, collecting data based on the place of service may not provide an accurate representation of the provider and patient population you are targeting. For this reason, modifiers are key; throughout the PHE, look for Current Procedural Terminology (CPT*)  Modifier 95 denoting “synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system” to home in on telehealth fraud and abuse during COVID-19.  

3. Pay Attention to Peers

Though there is still much uncertainty surrounding COVID-19 and the relatively new area of telehealth, there is a lot we do know today that can be used for benchmarking purposes. For instance, Commonwealth Fund data show that from mid- to late-March 2020, there was a marked decrease in overall healthcare utilization, including telehealth. During this time, we would expect to see a similar trend when looking at a single provider; however, recent telehealth investigations conducted by HMS’ SIU found providers who either experienced a minor dip in billing as compared to their peers, or hardly any dip at all. While not necessarily an indication of fraud in itself, unusual spikes or outliers such as these can serve as red flags for further investigation.

Spike reporting and outlier detection can also be a useful tool in detecting ordering and referral schemes, particularly with regard to durable medical equipment (DME). For example, a high ratio of orders between a particular healthcare provider and DME supplier — or compared to peer providers — could signify potential collusion.

4. Chart the Course

As we continue to gather data and assess the impact of COVID-19 on the healthcare ecosystem, being on high alert is critical to mitigating emerging fraud schemes before they cause serious and far-reaching damage. During the PHE especially, demonstrative evidence, such as charts and graphs, combined with strong benchmarking data, is key to identifying suspicious connections and unusual trends.

HMS continues to work closely with SIUs during the PHE to combat fraud, waste and abuse (FWA), with a particular focus on the rapidly evolving realm of telehealth. Our Telehealth FWA blog series includes data-driven insights to help healthcare organizations navigate the new healthcare normal, including red flags and emerging fraud schemes threatening the consumer and payer landscape. Learn more about our FraudCapture and other payment integrity solutions at


* CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

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