On April 25, 2023, the Department of Health and Human Services Office of Inspector General published a toolkit titled “Analyzing Telehealth Claims to Assess Program Integrity Risks" at https://oig.hhs.gov/oei/reports/OEI-02-20-00723.pdf. The toolkit provides ways to analyze telehealth claims to identify possible improper billing for telehealth services for individual providers, such as physician and non-physician practitioners. The toolkit was created to help Medicare Advantage plan sponsors, private health plans, state Medicaid Fraud Control Units, and other federal healthcare agencies in reviewing telehealth claims for accuracy and appropriate billing.
The toolkit includes steps (see below) to analyze claims for telehealth services, which can be used to identify program integrity risks and providers whose billing poses a high risk and warrants further scrutiny.
- Review program policies
- Collect claims data
- Conduct quality assurance checks
- Analyze data to identify program integrity risks
- Interpret the results of the analysis
Most importantly, the toolkit includes seven data analysis measures (see below) that can be applied to the user’s own data and can help indicate fraud, waste, or abuse.
- Billing telehealth services at the highest, most expensive level for a high proportion of services.
- Billing a high average number of hours of telehealth services per visit.
- Billing telehealth services for a high number of days in a year.
- Billing telehealth services for a high number of patients.
- Billing multiple plans or programs for the same telehealth service for a high proportion of services.
- Billing for a telehealth service and then ordering medical equipment for a high percentage of patients.
- Billing for both a telehealth service and a facility fee for most visits.
Due to the drastic increase in telehealth claims during the COVID-19 pandemic, the increase in potential fraud, waste, and abuse of federal and state healthcare programs also grew exponentially. Payers can utilize this toolkit to validate appropriate claims, and providers and hospitals can also use it to review telehealth claims for potential billing issues to mitigate risks. The toolkit provides seven program integrity measures as potential fraud, waste, and abuse.
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