On December 1, 2022, the Pandemic Response Accountability Committee issued a report on telehealth use and program integrity risks across selected health care programs during the first year of the COVID-19 pandemic. Given the debate on Capitol Hill about the permanent flexibilities in the Medicare program, we focus here on Medicare fee-for-service and Medicare Advantage, which HHS examined from March 2020 through February 2021, and the year prior from March 2019 through February 2020.

The report shared several impressive findings:

  • 37 million individuals used telehealth services across the programs of six federal agencies – an expansion from approximately 3 million individuals using telehealth in the prior year. Pre-pandemic, the vast majority of those telehealth visits were only available to veterans.
  • In Medicare, the expansion was huge – with over 80 times the number of individuals using telehealth in 2020.

The report identifies some potential areas of program integrity concern. While there will always be program integrity risks in federal programs, we urge policymakers to keep it in perspective. There is no evidence of a need for widespread concern related to telehealth in the Medicare program. In fact, the telehealth risks appear lower than in-person care.

HHS OIG Claim: “In total, Medicare paid over $5.1 billion for telehealth services for beneficiaries enrolled in Medicare fee-for-service. HHS OIG identified more than 300 Medicare providers who billed for telehealth services at the highest, most expensive level every time, totaling approximately $5.2 million.

  • Perspective:
    • The report identified 300 Medicare providers who billed for telehealth services at the highest, most expensive level every time was 0.1 percent of total Medicare payment for telehealth services for beneficiaries enrolled in Medicare fee-for-service. For 2020, Medicare spending was $829.5 billion for total Medicare services.
    • As context, the estimated Medicare total improper payment rate in 2020 was 6.27 percent, representing $25.74 billion in improper payments. Prior to the pandemic, the Medicare improper payment rate in 2019 was 25 percent. Other government watchdogs estimated $43 billion in FY 2020 for Medicare improper payments, accounting for over one-quarter of the total amount of improper payments made government-wide in fiscal year 2019.

HHS OIG Claim: “We identified over 1,700 providers whose billing for telehealth services poses a high risk to Medicare. Although these providers represent a small proportion of the approximately 742,000 providers who billed for a telehealth service, their billing raises concern.”

  • Perspective: An identification of providers who pose a high risk to Medicare does not indicate the presence of fraud – only that there are practices which should be monitored.
  • This point made by HHS OIG is out of context. OIG originally mentioned these providers in this report where they noted that more than half of those high-risk providers belonged to a medical practice that posed high risk billing to Medicare in general, not just telehealth. As such, the billing practices of these providers do not pose a risk solely as it relates to telehealth – they are risks to the Medicare program broadly that CMS should address.

HHS OIG Claim: “HHS OIG identified 138 providers who repeatedly billed both Medicare fee-for-service and a Medicare Advantage plan for the same telehealth service.”

  • Perspective: There are bad actors within the Medicare program, 138 providers is a low number for such billing practices to be occurring for the 28 million Medicare beneficiaries who used telehealth services and the $5.1 billion in spending on Medicare telehealth services during the first year of the pandemic.
    • In its September 2022 report on program integrity risks in Medicare telehealth services during the first year of the pandemic, HHS OIG noted that a total of 18,034 providers billed both Medicare fee-for-service and Medicare Advantage for the same telehealth service for the same beneficiary on the same date of service at least once. However, HHS OIG only classified providers as “high risk” if they billed this way for more than 20 percent of their claims and encounters – in this case 0.7 percent of providers who billed this way.
    • While OIG claims this could be an indicator of providers intentionally submitting duplicate claims to increase their Medicare payments, there is no concrete evidence to support this claim, nor is there an indication of the circumstances surrounding these claims (i.e., potential for practitioner error).
    • In 2018, OIG found that many of the disallowed payments for telehealth services were because of practitioner errors in understanding and meeting Medicare telehealth requirements. One of their recommendations was to offer education and training sessions to practitioners on Medicare telehealth requirements. Given that this was the case for the limited number of practitioners using telehealth in 2018, we have a hard time believing there were not many similar errors in 2020.

HHS OIG Claim: “HHS OIG identified 86 providers who billed for a high average number of hours of telehealth services per visit.”

  • Perspective: This again is a low number compared to the patients served and spending that occurred, and could be related to any number of factors such as practitioner error in codes used, the nature of the service rendered, or treatment of high-need patients.
    • In the same September 2022 report mentioned above, HHS OIG identified 86 providers that billed for an average of more than two hours of telehealth services per visit, compared to the median of 21 minutes of telehealth services per visit for all providers who billed for telehealth services. However, OIG does not note the types of services rendered for these longer visits, which is a critical data point necessary to make accurate comparisons to affirm whether there is call for widespread concern.
    • A visit with a psychotherapist who is treating a patient in crisis for a mental health or substance use disorder, for example, is going to require more intensive time and care compared to a visit for acute conditions. HHS OIG notes in a previous report that, during the first year of the pandemic, “beneficiaries used telehealth for 43 percent of behavioral health services, whereas they used telehealth for 13 percent of office visits.” Given the proliferation of telehealth for mental and behavioral health services in particular during the pandemic, this merits further analysis.

It’s important to note that this report recycles past policy recommendations made by HHS OIG. These recommendations include:

  • Strengthen monitoring and targeted oversight of telehealth services;
    • The Alliance has supported additional oversight to ensure bad actors do not undermine access to telehealth in Medicare.
  • Provide additional education to providers on appropriate billing for telehealth services;
    • The Alliance strongly agrees that provider education is useful, as accidental misbilling has in the past been interpreted as fraudulent. Similarly, HHS steps to simplify telehealth billing are welcomed.
  • Improve the transparency of “incident to” services when clinical staff primarily delivered a telehealth service;
    • The Alliance recognizes the importance of accurate data for analysis. We also stress the importance maintaining “incident to” services for healthcare practitioners unable to bill the Medicare program directly.
  • Identify telehealth companies that bill Medicare;
    • If a provider, including a virtual-only provider, wants to bill Medicare directly, they must enroll in Medicare, thereby giving CMS oversight of that provider. We don’t believe there is clear justification for singling out virtual-only providers, particularly when Medicare beneficiaries are overwhelmingly seeing providers that use telehealth services in addition to maintaining brick and mortar. Given that virtual-only is a new modality, limited steps to improve CMS’s understanding and oversight of these providers seems logical, and if it helps prevent limits on beneficiary access to telehealth, then we support it.
  • Require a modifier to identify all audio-only telehealth services provided in Medicare; and
    • HHS has already acted on this recommendation, with Alliance for Connected Care support.
  • Collect data on the use of telehealth in opioid treatment programs.
    • The Alliance recognizes the importance of accurate data for analysis and supports calls for additional data to further analyze this occurrence.
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