In a September 2022 brief concerning program integrity, the Health and Human Services Office of Inspector General (OIG) identified seven measures to identify providers who may present a high risk for improper Medicare telehealth billing.  These seven factors should serve as a guide to providers and their compliance officers when identifying potential fraud risk in connection with their telehealth programs.

The seven factors identified by the OIG as potentially indicative of telehealth fraud and abuse are as follows:

1. Billing both a telehealth service and a facility fee for most visits
2. Billing all telehealth services at the highest, most expensive level
3. Billing telehealth services for a high number of days in a year
4. Billing both Medicare fee-for-service and a Medicare Advantage Plan for the same service with a high proportion of services
5. Billing a high average number of hours of telehealth services per visit
6. Billing telehealth services for a high number of beneficiaries
7. Billing for a telehealth service and ordering medical equipment for a high proportion of beneficiaries.

The OIG based its assessment on an analysis of Medicare fee-for-service claims data and Medicare Advantage encounter data for the first year of the pandemic from March 1, 2020, to February 28, 2021.  A separate report by the OIG confirmed what we already knew: the use of telehealth increased dramatically during the pandemic with two out of every five Medicare beneficiaries accessing care by telehealth.  This amounts to approximately 88 times more telehealth encounters than were the norm prior to the onset of the pandemic.

The OIG based its criteria on data from approximately 742,000 providers who billed for a telehealth service.  Together with information from fraud investigators, the OIG developed the seven measures it claims may indicate fraud, waste, or abuse.  Only high-risk identifiers were included in the report and the OIG took special pains to point out these seven measures do not identify all telehealth billing concerns possibly occurring in Medicare.

Additionally, this report does not confirm any particular provider of telehealth services is engaging in fraudulent or abusive practices.  The OIG clarifies these indicators may be used as the basis to conduct further investigations into provider telehealth billing practices.  As a result, providers should take note of these factors and conduct audits or other activity to determine whether their practices could trigger such investigations.  Additionally, policies and procedures should be amended if necessary to direct staff to the types of practices considered suspect in order to avoid potential investigation by the OIG.  This is particularly advisable in view of the move toward data analysis by enforcement agencies to identify areas of potential abuse.