Healthcare Facility Fraud
The continued use of telemedicine – made dramatically more mainstream during the pandemic – may open the door for more fraud, waste, and abuse in health care claims. The number of fraud cases related to health care “more than doubled from 2019 to 2020 and was at the highest level ever reported” according to the National Law Review. For employers with self-funded health care plans it is just the latest reason to monitor health care claims for fraud and waste.
Early on, when telemedicine came into practice, rules and regulations regarding billing were in place outlining for providers and payers the specific reasons visits could be done via telemedicine. This was especially true for Medicare. However, when the pandemic hit and regulations were relaxed out of the necessity of the situation, that eliminated many barriers for those who wanted to take advantage of the system. The rise of telemedicine and the relaxation of some regulations injects a whole new opportunity for unscrupulous providers to bill plans deceptively.
Bill Young, SmartLight’s head of clinical operations who has 20 years of federal health care fraud investigative experience, said the types of fraud that might slip through the cracks via telemedicine are only limited by your imagination.
When the pandemic hit and regulations were relaxed out of the necessity of the situation, that eliminated many barriers for those who wanted to take advantage of the system.
“More common forms of telemedicine fraud involve provider billing and coding errors, which will only increase in volume as CMS (Center for Medicare & Medicaid Services) continues to expand its list of reimbursable telehealth services,” according to the American Health Law Association.
“As more patient-physician interfacing occurs over telehealth platforms, CMS will closely monitor reimbursement requests from providers to monitor potential for up-coding the amount of time spent with patients and the complexity of the services rendered. There will also be opportunity for fraud in misrepresenting the virtual services provided. Different CPT codes apply depending on the type of patient-provider interaction and whether that meeting is synchronous or asynchronous. In this virtual environment, it is now much easier for a health care provider to fraudulently bill for the CPT code that will give him greater reimbursement or bill for a service he never rendered.”
“I don’t know if you can put that genie back in the bottle,” Young said. “Everyone has gotten accustomed to the relaxed rules but there will have to be some effort to reinstate some of the telemedicine requirements prior to COVID because otherwise you might as well just open the bank vault.”
In terms of examining health care claims data, employers were not equipped to monitor employee health care claims before telemedicine and other digital health care trends arose. They are no closer to doing so now.
“It just throws another wrench into the system and gives employers all the more reason to scrutinize their health care claims data because telemedicine has just injected a whole new opportunity for unscrupulous providers to bill these employers and if you’re not watching the store the money is just going to go out the door,” Young said.
There is a place for telemedicine in the health care system but as we move forward technology will continue to give rise to different ways of delivering health care.
And while we are seeing telemedicine numbers drop – a reported 12.5% drop in April 2021 – the use of it will not go away. A bill was introduced in Congress in late 2021 to permanently extend telemedicine waivers issued during the pandemic. This bill, according to mHealth Intelligence, “tackles some of the most noteworthy waivers introduced by the Centers for Medicare & Medicaid Services over the past year and a half to expand telehealth coverage and access during the coronavirus pandemic … to make sure those freedoms continue after the public health emergency has ended. … The bill would allow the Health and Human Services Secretary to expand the list of health care providers able to use telehealth, and it would clarify fraud and abuse laws to give providers more leeway to use telehealth and remote patient monitoring platforms.”
There is a place for telemedicine in the health care system but as we move forward technology will continue to give rise to different ways of delivering health care. In fact, we’re already seeing situations such as texting with online telemedicine companies opening access to health care. But all these situations also open the door for fraud, waste, and abuse in a unique way that we haven’t seen before. For employers, that means continually trying to keep up.Healthcare Diversion Healthcare Fraud New Trends Telemedicine