The use of telehealth services continues to grow throughout the country. Nearly all state Medicaid programs allow beneficiaries to receive their services through the telehealth medium. Telehealth services use information and telecommunications technologies to support and promote long-distance clinical health care and administration. With the rise in telehealth use and availability, government scrutiny of telehealth arrangements has also increased. In the past few months, the Department of Health and Human Services Office of Inspector General (OIG) has published a new audit report and issued an advisory opinion that indicates its focus on telehealth arrangements.
OIG on Distant-Site Telehealth Claims
In April 2018, the OIG issued an Audit Report regarding the Centers for Medicare & Medicaid Services’ (CMS) payment to practitioners for telehealth services that did not meet the Medicare requirements. The Medicare telehealth spending increase from $61,302 in 2001 to $17,601,996 in 2015 prompted the OIG to conduct this review. Medicare telehealth payments include a professional fee that is paid to the practitioner performing the service at a distant site. The payment also includes an originating-site fee, which is paid to the facility where the service is performed for the beneficiary.
During the OIG’s 2014 to 2015 review period, more than half of the 191,118 distant-site telehealth claims paid by Medicare did not have matching originating-site facility fee claims. The OIG noted that a Medicare Payment Advisory Commission study of 2009 claims found that professional fee claims without corresponding claims for originating-site facilities fees were more likely to be associated with unallowable Medicare telehealth payments. Accordingly, the OIG focused its April 2018 review on these distant-site telehealth claims that did not have a corresponding originating-site fee. Based on their review sample of 100 claims, approximately 30 percent did not meet Medicare requirements. The OIG further estimated that proper practitioner payments could have saved Medicare $3.7 million during the audit period. To address the issue, the OIG recommended that CMS: 1) conduct periodic post-payment reviews to disallow payments for errors for which telehealth claim edits cannot be implemented; 2) work with Medicare contractors to implement all telehealth claim edits listed in the Medicare Claims Processing Manual; and 3) offer education and training sessions to practitioners on Medicare telehealth requirements and related sources.
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Further, in May 2018, the OIG issued Advisory Opinion 18-03 to assess whether a proposal by a federally qualified health center look-alike (FQHC look-alike) to provide free telemedicine items and services to a county Department of Health’s clinic (the Proposed Arrangement) would violate the federal Anti-Kickback Statute (AKS). The OIG stated that the Proposed Arrangement could potentially result in illegal remuneration from the FQHC look-alike to the clinic in exchange for referrals. However, the OIG concluded that given the presence of certain safeguards to prevent patient steering, the Proposed Arrangement posed a low risk of fraud and abuse under the AKS. The Proposed Arrangement would be unlikely to increase costs to federal health care programs. Further, the OIG noted that the Proposed Arrangement would actually result in significant health benefits to the public. Based on its analysis, the OIG stated that it would not impose administrative sanctions against the parties involved in the Proposed Arrangement.
With limited Medicare reimbursement, providers continue to face the challenge of treating patients through telemedicine services. However, providers should be aware that in 2019, the Bipartisan Budget Act of 2018 will introduce some improvements to the area of telehealth services.
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