With Telehealth Expansion, New Fraud, Waste & Abuse Vulnerabilities Emerge

June 23, 2020 HMS

A global pandemic has brought many of the long-touted benefits of telehealth to the forefront.

  • For consumers, particularly the elderly, immunocompromised and those living in resource-scarce communities, telehealth offers a home-based option at a time when visiting a healthcare facility is unusually high risk or may be unfeasible.
  • Providers can remotely screen and monitor patients with COVID-19 symptoms without putting themselves, their staff or other patients at risk, while also maximizing resources during a high-demand period for healthcare.
  • Healthcare organizations benefit from the level of connectivity virtual care platforms and remote monitoring tools afford, enabling a more efficient and consumer-friendly healthcare experience.

Unfortunately, there is another party that may stand to benefit from the rapid shift to telehealth as well as the conditions fueling it. Fraudsters, who, as history has shown, tend to thrive in crisis, are already making their presence known in today’s uncertain environment. The U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) has reported a number of COVID-19 related fraud schemes ranging from telemarketing calls to unsolicited text messages to door-to-door visits from scammers offering fake COVID-19 tests.

Amid the pandemic, the federal government expanded telehealth coverage for Medicare beneficiaries in an effort to help mitigate the spread of the coronavirus and protect vulnerable consumers. In doing so, it also relaxed a number of regulatory guidelines to help facilitate access to these services. This has led to growing concern about a potentially heightened risk of telehealth-related fraud, waste and abuse.

 How COVID-19 Changed the Telehealth Rules — and Risks

Despite years of buzz and industry advocacy, telehealth, also known as telemedicine, has been slow to evolve. Now, thrust into the spotlight by a pandemic, it’s looking more and more like it’s here to stay. According to The Physicians Foundation’s 2018 Survey of America’s Physicians, telemedicine use among providers has increased from 18% in 2018 to 48% in 2020. Unsurprisingly, digital health stocks, including telehealth, are continuing to soar, as what was largely an emerging trend just months ago is quickly becoming the new normal.

The sudden, rapid evolution of telehealth and, specifically, the easing of regulations to accommodate it, calls into question the long-term sustainability of the current landscape. The Centers for Medicare and Medicaid Services (CMS) provides a full list of these relaxation measures, of which the following are of note:

  • Potential penalties for HIPAA violations may be waived in order to encourage use of teleconferencing technologies — a move that raises concerns around patient privacy and safety.
  • Physicians may reduce or waive patient deductibles and copayments for telehealth visits — an act that, under normal circumstances, could be considered a kickback.
  • Granted certain conditions are met, out-of-state practitioners do not have to be licensed in the state in which they are providing telehealth services, which has some legal experts sounding alarms on potential liability and malpractice implications.

Though initially introduced as temporary, it is likely that at least some of these flexibilities could endure beyond the current crisis. This is significant given telehealth’s track record of fraud, waste and abuse. In a 2018 report, HHS OIG found that, during a 2014–2015 audit period, CMS paid 31 out of 100 telehealth claims that did not meet Medicare requirements, equaling $3.7 million in overpayments. In 2019, federal law enforcement charged 35 defendants from dozens of telemedicine and cancer genetic testing laboratories in connection with a $2.1 billion Medicare fraud scheme. Months earlier, 24 people were charged in a $1.2 billion telemedicine fraud scheme involving durable medical equipment.

Of course, not all telehealth fraud schemes are high profile, nor are all instances of improper billing the result of intentional wrongdoing. Today especially, providers are navigating unprecedented circumstances, with new information and guidelines emerging by the minute. In addition to new ICD-10, CPT and HCPCS codes for COVID-19, CMS has approved 80 additional billing codes for telehealth services.

Change and uncertainty abound; the system and its staff are stressed. In this environment, coding and billing inaccuracies are, to some degree, inevitable. For these reasons, healthcare organizations should adopt a measured and flexible approach in reinstating program integrity measures during and post-pandemic.

Will the Value of Telehealth Outweigh the Risks?

Many are convinced the proverbial toothpaste is out of the tube with regard to telehealth — an assertion that is difficult to argue given its surge in popularity over the last several months.

It is also becoming clear that navigating this new healthcare landscape could require some reverse engineering, as COVID-19 has forced a rapid transformation of many different systems and the policies that govern them. This will be essential in embracing the value of telehealth while mitigating its inherent risks, protecting the health and safety of vulnerable consumers.

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