We will review the OUD treatment services that were reimbursed under the bundle payments provided to people enrolled in Medicare. We will determine the types, delivery methods (i.e., in person or via telehealth), and frequency of OUD treatment services provided to Medicare enrollees by OTPs that received bundled payments. We will compare the bundled payments for OUD treatment services with the reimbursement amount of the actual OUD treatment services if the services were not part of the bundled payment. We will also determine whether these services complied with certain Medicare requirements.
The purpose of the adult partial care program is to provide Medicaid beneficiaries with serious mental illnesses individualized outpatient clinic services to reduce unnecessary hospitalizations. Our prior audit made a financial recommendation and procedural recommendations to the State agency to improve its guidance and monitoring. This audit work will determine whether the State agency adequately implemented our prior recommendations. We will also review claims for compliance with Federal and State requirements, including the State agency’s implementation of telehealth services due to the COVID-19 pandemic.
Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency
We will evaluate home health services provided by agencies during the COVID-19 public health emergency to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with Medicare requirements. We will report as overpayments any services that were improperly billed. We will make appropriate recommendations to CMS based on the results of our review.
Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency
Phase one audits will focus on making an early assessment of whether services such as evaluation and management, opioid use disorder, end-stage renal disease, and psychotherapy (Work Plan number W-00-21-35801) meet Medicare requirements. Phase two audits will include additional audits of Medicare Part B telehealth services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits to determine whether Medicare requirements are met.
Medicaid—Telehealth Expansion During COVID-19 Emergency
Our objective is to determine whether State agencies and providers complied with Federal and State requirements for telehealth services under the national emergency declaration, and whether the States gave providers adequate guidance on telehealth requirements.
Telehealth Services in Select Federal Health Care Programs
The selected programs in six Federal agencies took steps to make telehealth available during the COVID-19 pandemic and provided relatively similar coverage of telehealth services. OIGs identified several program integrity risks associated with billing for telehealth services that were similar across multiple health care programs, such as risks involving inappropriate billing for the highest, most expensive level of telehealth services and risks related to duplicate claims and high-volume billing. OIGs found limited information about the impact of telehealth on quality of care, which has implications for the care provided to individuals and program integrity. OIGs found that programs lack some data necessary for oversight of telehealth services.
Home Health Agencies’ Challenges and Strategies in Responding to the COVID-19 Pandemic
Findings: Like all health care providers, HHAs have experienced multiple challenges to providing care during the COVID-19 pandemic. HHAs have continued to experience longstanding staffing challenges as well as new ones resulting from the pandemic, such as maintaining staffing despite quarantine and isolation protocols. These staffing challenges persist for many HHAs despite efforts to address them. In addition, HHAs faced numerous and widespread infection control challenges, including accessing personal protective equipment (PPE) to limit exposure and spread, but these have mostly eased since early in the pandemic. Telehealth flexibilities under the public health emergency have also helped HHAs provide care while reducing COVID-19 exposure and dealing with staffing shortages.
Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use Telehealth During the First Year of the COVID-19 Pandemic
Findings: Beneficiaries in urban areas were more likely than those in rural areas to use telehealth during the first year of the pandemic. Beneficiaries in Massachusetts, Delaware, and California were more likely than beneficiaries in some other States to use telehealth. Dually eligible beneficiaries (i.e., those eligible for both Medicare and Medicaid), Hispanic beneficiaries, younger beneficiaries, and female beneficiaries were also more likely than others to use telehealth. In addition, beneficiaries almost always used telehealth from home or other non-health-care settings. Furthermore, almost one-fifth of beneficiaries used certain audio-only telehealth services, with the vast majority of these beneficiaries using these audio-only services exclusively. Older beneficiaries were more likely to use these audio-only services, as were dually eligible and Hispanic beneficiaries.
Medicare Telehealth Services During the COVID-19 Pandemic: Program Integrity Risks
Finding: OIG identified 1,714 providers whose billing for telehealth services during the first year of the pandemic poses a high risk to Medicare. These providers billed for telehealth services for about half a million beneficiaries. They received a total of $127.7 million in Medicare fee-for-service payments. Each of these 1,714 providers had concerning billing on at least 1 of 7 measures OIG developed that may indicate fraud, waste, or abuse of telehealth services. All of these providers warrant further scrutiny. For example, they may be billing for telehealth services that are not medically necessary or were never provided. In addition, more than half of the high-risk providers we identified are a part of a medical practice with at least one other provider whose billing poses a high risk to Medicare. This may indicate that certain practices are encouraging such billing among their associated providers. Further, 41 providers whose billing poses a high risk appear to be associated with telehealth companies; however, there is currently no systematic way to identify these companies in the Medicare data.
Use of Medicare Telehealth Services During the COVID-19 Pandemic
Findings: Beneficiaries used 88 times more telehealth services during the first year of the pandemic than they used in the prior year. Beneficiaries’ use of telehealth peaked in April 2020 and remained high through early 2021. Overall, beneficiaries used telehealth to receive 12 percent of their services during the first year of the pandemic. Beneficiaries most commonly used telehealth for office visits, which accounted for just under half of all telehealth services used during the first year of the pandemic. However, beneficiaries’ use of telehealth for behavioral health services stands out. Beneficiaries used telehealth for a larger share of their behavioral health services compared to their use of telehealth for other services. Specifically, beneficiaries used telehealth for 43 percent of behavioral health services, whereas they used telehealth for 13 percent of office visits.
Data Snapshot: Review of Beneficiaries Relationships With Providers for Telehealth Services
Findings: Most beneficiaries received telehealth services from providers with whom they had an established relationship. Notably, 84 percent of beneficiaries received telehealth services only from providers with whom they had an established relationship. Those enrolled in traditional Medicare were more likely to receive services from providers with whom they had an established relationship, compared to beneficiaries in Medicare Advantage. This pattern persisted among virtually all of the most common telehealth services. Beneficiaries tended to see their providers in person about 4 months prior to their first telehealth service, on average.
Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care (Part 1)
Findings: While most States can identify which services are provided via telehealth, a few reported being unable to, limiting their ability to evaluate and oversee telehealth. In addition, only a few States have evaluated the effects of telehealth in their State; these States found increased access and reduced costs. Based on their own experiences, other States believe that telehealth increases access, has uncertain impacts on costs, and raises concerns about quality. Further, despite concerns about fraud, waste, and abuse, many States do not conduct monitoring and oversight specific to telehealth.
Use of Telehealth to Provide Behavioral Health Services in Medicaid Managed Care (Part 2)
Findings: Most States reported multiple challenges with using telehealth, including a lack of training for providers and enrollees, limited internet connectivity for providers and enrollees, difficulties with providers’ protecting the privacy and security of enrollees’ personal information, and the cost of telehealth infrastructure and interoperability issues for providers. Some States also reported other challenges, including a lack of licensing reciprocity and difficulties with providers obtaining informed consent from enrollees. These challenges limit States’ ability to use telehealth to meet the behavioral health needs of Medicaid enrollees.