Nearly one-third of telemedicine claims reviewed by HHS’ Office of Inspector General did not meet Medicare requirements, which added up to an estimated $3.7 million in additional costs, according to a new OIG report.
As part of a review, OIG examined 191,118 Medicare paid distant-site telehealth claims from 2014 and 2015, which totaled $13.8 million.
Then, the office took a random sample of 100 claims. Sixty-nine of those claims met telehealth service requirements. But the other 31 did not, resulting in an estimated $3.7 million in extra costs.
Here’s a breakdown of where the problems occurred:
- For 24 claims, beneficiaries “received services in nonrural settings at sites that were not participating in a demonstration program.” Aside from a couple exceptions, Medicare only covers telehealth services for patients at a rural originating site. But one patient’s originating site was Lynchburg, Virginia, which is considered a metropolitan area.
- Seven claims were billed by ineligible institutional providers. Institutional facilities at a distant site can only bill Medicare for telemedicine if “the facility is a [critical access hospital] that elected the Method II payment option and the practitioner reassigned his or her benefits to the CAH” or if “the facility provided [medical nutrition therapy] services.”
- In three claims, beneficiaries received services at unauthorized originating sites. Two patients were at their homes when the telehealth service was provided, and one individual was at an independent renal dialysis facility. Neither location is considered eligible.
- Two claims involved practitioners who used an unallowable means of communication. In one instance, the service was provided via telephone instead of an interactive telecommunications system. For the other claim, the service involved the use of an asynchronous store and forward telecommunications system. This is only allowed when the originating site is a federal telemedicine demonstration project in Alaska or Hawaii, and in this case, it wasn’t.
- In one claim, a practitioner provided a noncovered service. The medical professional provided crisis psychotherapy using telehealth, even though it is not on the approved list of services.
- One claim involved a practitioner located outside the United States. Generally speaking, Medicare doesn’t reimburse services provided outside America. In this situation, a physician living and practicing in Pakistan provided psychiatric services via telehealth to a patient at a rural medical center in the United States.
OIG suggested CMS take several steps to ensure improper reimbursement doesn’t continue. For instance, it recommended conducting regular post-payment reviews, working with Medicare Administrative Contractors to implement telehealth claim edits and educating practitioners on Medicare telehealth reimbursement requirements.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
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