Federal Agencies Watching for Medicare Abuse as Telehealth Expanded during the Pandemic

May 17, 2021

At the end of April, the U.S. Department of Justice (DOJ) announced that two nurse practitioners in Montana admitted that they conspired to cheat Medicare out of millions of dollars by exploiting telemedicine provisions.

Since the start of the Covid-19 pandemic, waivers and flexibilities have enabled Medicare beneficiaries to access more telehealth services without having to travel to healthcare facilities. Opening up the restrictions on telehealth, however, brought the potential for billing fraud and abuse with the healthcare system.

Richard Kusserow of Strategic Management Services called out in his blog this spring, “These actions made oversight, enforcement, transparency, program integrity and accountability more important.”

“There is widespread consideration being given to expanding coverage for telehealth services based on the experience providers and patients have had during the pandemic,” Kusserow noted. “For most, the expansion of telehealth services has been viewed positively due to opportunities to increase access, decrease burdens, and enable better care.”

The HHS OIG is actively watching out for bad actors such as the nurse practitioners who tried to take advantage of telehealth provisions. In the fall of 2020, the DOJ announced that it had charged 345 people, including doctors, nurses and other medical professional across 51 federal districts in what the agency called the largest healthcare fraud takedown in history. Charges accounted for more than $6 billion in fraud, including more than $4.5 billion connected to telehealth.

Healthcare Finance Magazine reported that 86 defendant telehealth executives allegedly paid doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and pain medications, either without any patient interaction or with only a brief phone conversation with patients they had never met or seen.  

In addition to the criminal charges, the Centers for Medicare and Medicaid Services' (CMS) Center for Program Integrity separately announced that it has taken a number of administrative actions related to telehealth fraud, revoking the Medicare billing privileges of 256 additional medical professionals for their involvement in various schemes.

Mike Cohen, an operations officer with the Health and Human Services Inspector General's Office, told Kaiser Health News in April that anti-fraud “guardrails have been removed under this epidemic. The concern is that things will never go back to what they were. … There will be a lot of pressure on CMS to make at least some of these changes permanent.”

CMS is under that pressure as the agency, providers and payers weigh the long-term use of telehealth as its use has drastically increased during the pandemic.

As Kusserow noted in his blog, Christi Grimm, Principal Deputy Inspector General of the Department of Health and Human Services (HHS), issued a statement regarding telehealth issues that have resulted from the Covid-19 pandemic.  In her announcement earlier this year, Grimm emphasized the importance of new policies and technologies are not compromised by fraud, abuse, or misuse.

Grimm reported that the HHS Office of the Inspector General (OIG) is conducting significant oversight work to uncover any fraudulent activity during the public health emergency. These reviews, with reports to be released later this year, will provide objective findings and recommendations that can assist policymakers who are considering which telehealth flexibilities can be made permanent.

The OIG is also continuing to focus on “telefraud” schemes and has conducted several large investigations of fraud schemes that inappropriately leveraged the reach of telemarketing schemes. Telehealth has become so popular during the coronavirus pandemic that it's drawing increased scrutiny from federal regulators. Regulators are also noting the technical differences between telehealth fraud and telefraud, mHealth Intelligence reported.

In an article advocating for Congress to act to ensure continued telehealth access, Health Affairs, a journal covering health policy and research, also noted that “Telehealth services may prove even easier to monitor for fraud and abuse because of the digital footprint created by these services. Moreover, CMS and the Office of Inspector General (OIG) at HHS have the same fraud and abuse authorities to monitor telehealth compliance as they do for any other Medicare-covered service.”

 


See additional resources and insights from SAI Global for managing healthcare compliance during the pandemic.

Read our annual healthcare compliance benchmark report (2021).

Learn more about our risk and compliance solutions for healthcare and health insurance organizations.

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