Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-20-00720
- Document type
- Brief
- Date
- 2020-03-01
Summary
A data brief from the U.S. Department of Health and Human Services Office of Inspector General, OEI-02-20-00720, dated September 2022, titled Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks. Based on Medicare claims and encounter data from March 1, 2020, to February 28, 2021, it reports identifying 1,714 providers, out of approximately 742,000, whose billing for telehealth services poses a high risk to Medicare on at least one of seven measures. The brief states these providers received a total of $127.7 million in Medicare fee-for-service payments and that it does not confirm any provider is engaging in fraudulent practices. It details 672 providers who billed both a facility fee and a telehealth service for most visits. OIG recommends five steps for CMS, which concurred with following up on the identified providers.
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U.S. Department of Health and Human Services
Office of Inspector General
Data Brief
September 2022, OEI-02-20-00720
Medicare Telehealth Services During the First Year of the Pandemic:
Program Integrity Risks
Why OIG Did This Review
Key Takeaways The COVID-19 pandemic created unprecedented challenges for
o Our findings demonstrate the how Medicare beneficiaries access health care. In response, the
importance of effective, Department of Health and Human Services (HHS) and the Centers
targeted oversight of for Medicare & Medicaid Services (CMS) took a number of
telehealth services to ensure actions to temporarily expand access to telehealth for Medicare
that the benefits of telehealth beneficiaries. 1 In addition, CMS temporarily paused several
are realized while minimizing program integrity activities, including medical reviews of claims. 2
risk.
In a related report, the Office of Inspector General (OIG) found
o We identified 1,714 providers
that the use of telehealth increased dramatically during the first
out of approximately 742,000
whose billing for telehealth year of the pandemic. 3 More than 28 million Medicare
services poses a high risk to beneficiaries—about 2 in 5—used telehealth services that first
Medicare. year. In total, beneficiaries used 88 times more telehealth
services during the first year of the pandemic than they did in the
o Each of these providers had
concerning billing on at least
prior year.
one of seven measures that
The changes to Medicare telehealth policies, along with the
may indicate fraud, waste, or
dramatic increase in the use of telehealth, underscore the
abuse.
importance of determining whether providers are billing for
o These providers billed for telehealth services appropriately and how to best protect
telehealth services for about Medicare and beneficiaries against fraud, waste, and abuse.
half a million beneficiaries.
o Many of these providers are a This data brief describes providers’ billing for telehealth services
part of the same medical and identifies ways to safeguard Medicare from fraud, waste, and
practice as at least one other abuse related to telehealth. This information can help CMS,
provider whose billing poses a Congress, and other stakeholders determine what safeguards
high risk. may be needed as they consider permanent changes to
telehealth policies in Medicare.
This report is part of a series that examines the use of telehealth in Medicare and the characteristics of
beneficiaries who used telehealth during the pandemic. 4
How OIG Did This Review
This data brief is based 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. We
focused our analysis on the approximately 742,000 providers who billed for a telehealth service. Using
input from OIG investigators, we developed seven measures that focus on different types of billing for
telehealth services that may indicate fraud, waste, or abuse. For each of these measures, we set very
high thresholds to identify providers whose billing poses a high risk to Medicare. Because this data
brief focuses on specific measures with very high thresholds, it does not capture all concerning billing
related to telehealth services that may be occurring in Medicare. Additionally, this report does not
confirm that any particular provider is engaging in fraudulent or abusive practices. Any determination
of fraud or an overpayment would require additional investigation.
Further, a Medicare billing practice—known as “incident to” billing—creates challenges for oversight
because it allows services provided by clinical staff who are directly supervised by a practitioner to be
billed under the supervising practitioner’s identification number. It is critical for program integrity
efforts to identify the individual who delivered the telehealth service that is billed to Medicare. To
address these limitations in the data, we developed measures for this report that aim to minimize the
effect of “incident to” billing on the results of the claims analysis.
What OIG Found
We 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 we 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.
What OIG Recommends
Although these high-risk providers represent a small proportion of all providers who billed for a
telehealth service, these findings demonstrate the importance of strong, targeted oversight of
telehealth services. The findings also offer insight on how Medicare and others can protect
beneficiaries against fraud, waste, and abuse. Conducting targeted oversight of telehealth will help
ensure the benefits of telehealth are realized while minimizing risk in an effective and efficient manner.
Accordingly, we recommend that CMS: (1) strengthen monitoring and targeted oversight of telehealth
services, (2) provide additional education to providers on appropriate billing for telehealth services, (3)
improve the transparency of “incident to” services when clinical staff primarily delivered the telehealth
service, (4) identify telehealth companies that bill Medicare, and (5) follow up on the providers identified
in this report. CMS concurred with our recommendation to follow up on the providers identified in this
report, but CMS did not explicitly indicate whether it concurred with the other four recommendations.
Primer on: Medicare Telehealth Services During the Pandemic
Medicare telehealth services refer to services that are provided remotely
using technology between a provider and a beneficiary.5
The services that can be provided via telehealth include office visits,
behavioral health services, nursing home visits, and home visits, among
others. Most of these services can also be provided in person. (See Appendix
A for a description of these services.)
A group of services known as virtual care services is always provided
remotely.6 An example of these services is a telephone call with a provider to
discuss a beneficiary’s medical condition.
During the pandemic, CMS allowed beneficiaries to use telehealth to access a
wide range of services in different locations, including in urban areas and
from the beneficiary’s home. Prior to the pandemic, beneficiaries were
allowed to use telehealth only from medical facilities located in rural areas, with
a few exceptions.7
During the pandemic, CMS increased the types of services that beneficiaries
could use via telehealth, from 118 to 264 services.8 Medicare pays providers
the same rate for services provided via telehealth and in person.
During the pandemic, CMS expanded the use of audio-only for certain types
of telehealth services, such as office visits and behavioral health services. Prior
to the pandemic, only audio-video was allowed for the delivery of telehealth
services, with a few exceptions.9
56789
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Primer | 3
RESULTS
This data brief describes providers’ billing for telehealth services during the first year
of the pandemic and identifies ways to safeguard Medicare from fraud, waste, and
abuse related to telehealth. Each of the providers identified in this report had
concerning billing on at least one of seven measures we developed that may indicate
fraud, waste, or abuse. (See Exhibit 1.) For each measure, we set very high thresholds
to identify providers who had concerning billing. Because this data brief focuses on
specific measures with very high thresholds, it does not capture all concerning billing
related to telehealth services that may be occurring in Medicare.
The seven measures that we developed focus on different types of billing for
telehealth services that may indicate fraud, waste, or abuse. Some of these billing
practices also occur with in-person services, such as always billing for the most
expensive codes. These measures do not include telemarketing fraud that does not
involve billing for telehealth services. Telemarketing fraud—often referred to as
telefraud—generally involves a phone call or other remote interaction with a
beneficiary to order or prescribe medically unnecessary testing, equipment, or
prescriptions. 10 This data brief is based on 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. 11
Exhibit 1: Program Integrity Measures
To identify providers whose billing for telehealth services poses a high risk to Medicare, we
developed seven measures based on analyses of the Medicare data and input from OIG
investigators. These measures focus on different types of billing that providers may use to
inappropriately bill for telehealth services and include:
billing both a telehealth service and a facility fee for most visits;
billing telehealth services at the highest, most expensive level every time;
billing telehealth services for a high number of days in a year;
billing both Medicare fee-for-service and a Medicare Advantage plan for the same
service for a high proportion of services;
billing a high average number of hours of telehealth services per visit;
billing telehealth services for a high number of beneficiaries; and
billing for a telehealth service and ordering medical equipment for a high proportion of
beneficiaries.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Results | 4
More than 1,700 providers billed for telehealth services in a
manner that poses a high risk to Medicare
In total, we identified 1,714 providers whose billing for telehealth services during the
first year of the pandemic posed a high risk to Medicare. Each of these providers had
concerning billing on at least one of seven measures we developed that may indicate
fraud, waste, or abuse of telehealth services. Although these providers represent a
small proportion of the approximately 742,000 providers who billed for a telehealth
service, their billing raises concern.
These seven measures focus on different types of billing that providers may use to
inappropriately maximize their Medicare payments. For each of these measures, we
set very high thresholds to identify providers who had concerning billing. There could
be additional providers with concerning billing that fell below our thresholds.
Additionally, this report does not confirm that a particular provider is engaging in
fraudulent or abusive practices. Any determination of fraud or an overpayment would
require additional investigation.
The vast majority (1,696) of the providers we identified had concerning billing on 1 of
the 7 measures, while 18 providers had concerning billing on 2 measures. Each of
these 1,714 providers warrant further scrutiny. They may be billing for telehealth
services that are not medically necessary or were never provided. Their billing also
raises concerns about the quality of services being provided. 12
In total, these 1,714 providers billed
for telehealth services for about half a
Providers Whose Billing Poses a
million beneficiaries. They received a
High Risk to Medicare
total of $127.7 million in Medicare
fee-for-service payments. 13 This o Billed telehealth services for
amount—and all dollar amounts in about half a million
this report—are those paid by beneficiaries.
Medicare fee-for-service only; the o Received a total of $127.7
amounts paid by Medicare million in Medicare fee-for-
Advantage plans to providers are not service payments.
reported to Medicare.
In addition, multiple providers with
concerning billing are a part of the same medical practice. In total, 991 of the 1,714
providers are a part of the same medical practice as at least one other provider whose
billing poses a high risk. 14 This may indicate that certain practices encourage such
billing among their associated providers.
Further, 41 providers who had concerning billing appear to be associated with
telehealth companies—companies that employ practitioners to provide on-demand
telehealth services to beneficiaries. 15 Unlike other providers, telehealth companies do
not offer in-person services. We identified providers who appear to be associated
with a telehealth company by reviewing the name of the provider billing Medicare;
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Results | 5
there is currently no systematic way to identify these companies in the Medicare data.
These providers billed both Medicare fee-for-service and Medicare Advantage plans
for telehealth services.
It is important to note that a Medicare billing practice—known as “incident to”
billing—creates challenges for oversight. “Incident to” billing allows for services
provided by clinical staff who are directly supervised by a practitioner to be billed
under the supervising practitioner’s identification number. Identifying the individual
who delivered the telehealth service that is billed to Medicare is critical to program
integrity efforts. To address these limitations in the data, we developed measures for
this report that aim to minimize the effect of “incident to” billing on the results of the
claims analysis.
More than 670 providers billed inappropriately for both a
telehealth service and a facility fee for most of their visits
A total of 672 providers billed
for both a facility fee—also
known as an originating site Billing for Telehealth Services
fee—and a telehealth service for
When a beneficiary receives a telehealth
more than 75 percent of their
service in a facility—such as a hospital
telehealth visits. A provider
or physician’s office—from a physician
should not bill for both the
or practitioner located at a separate
facility fee and a telehealth
location, the facility can charge
service for the same visit. 16
Medicare a facility fee for hosting the
Billing for both would mean that telehealth service.
the provider and beneficiary The physician or practitioner who
were at the same physical provides the telehealth service may not
location when the telehealth bill for the facility fee.
service was provided; therefore,
the provider is not allowed to
deliver a telehealth service. 17
Although some providers may be billing this way in error, others may be billing this
way to inappropriately maximize their Medicare payments for each visit.
These 672 providers billed for both the facility fee and a telehealth service for about
148,000 visits, totaling more than $14.3 million for facility fees and telehealth services.
In total, 21 providers billed for both the facility fee and a telehealth service for more
than 1,000 visits each. Further, 57 providers billed this way for all of their visits.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Results | 6
Examples of providers who billed for both a facility fee and a telehealth
service
Two providers—a psychiatrist and psychologist—billed for both a facility fee and a
telehealth service for more than 90 percent of their visits, amounting to nearly
4,000 visits each. These providers billed facility fees and telehealth services
totaling approximately $1.1 million.
More than 360 providers always billed telehealth services at the
highest, most expensive level
In total, 365 providers billed for certain telehealth services at the highest, most
expensive level every time. 18 Providers can bill certain services at different levels
depending on the complexity of the beneficiary’s condition or the duration required
to diagnose and treat a beneficiary.
Billing for the highest level of complexity or duration when that is not what was
needed or provided is one scheme that unscrupulous providers use to inappropriately
increase their Medicare payments. Payments for the highest level range from nearly
two times to almost eight times more than the lowest level. This practice is often
referred to as “upcoding.” In these cases, providers may be delivering higher levels of
services than medically necessary or billing for levels of services that were not
rendered.
Office visits provided via telehealth: In total,
170 providers always billed for office visits Office Visits
provided via telehealth at the highest, most
expensive level possible. In contrast, most 170 providers always
providers who billed for these types of visits billed at the highest level.
never billed at the highest level. (See
14 providers billed for
Appendix B for a description of the different
prolonged services
levels of each of these types of services.)
beyond the highest level
These 170 providers billed for about 34,400 for more than half of
telehealth office visits, all at the highest level. their visits.
Medicare fee-for-service payments for these
visits totaled $2.2 million. Two of these
providers billed the highest level for more than 1,300 visits each.
In some cases, providers billing at the highest levels were concentrated in specific
medical practices. In total, 21 medical practices had multiple providers who always
billed at the highest level for telehealth office visits. In one case, a single medical
practice had 30 providers who always billed at the highest level.
In addition to always billing at the highest level, 14 providers billed for additional
time, prolonging the office visits past the highest level, for more than half of their
visits. 19 One provider billed this way for more than 90 percent of the provider’s
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Results | 7
telehealth office visits. Providers who bill for prolonged office visits that extend
beyond the time at the highest level receive additional payment.
Other types of visits provided via
telehealth: An additional 195 providers
always billed for other types of visits at the
Other Visits
highest, most expensive level. These types of
visits included home visits, nursing home 140 providers always
visits, or assisted living visits that were billed telehealth home
provided via telehealth. 20 In contrast, most visits at the highest level.
providers almost never billed the highest level
for any of these services. 41 providers always billed
telehealth nursing home
These 195 providers billed for about 40,300 visits at the highest level.
visits, totaling almost $3 million in Medicare
fee-for-service payments. Five of these 19 providers always billed
providers billed at the highest level for more telehealth assisted living
than 1,000 visits each. One provider not only visits at the highest level.
billed exclusively for the highest level possible
of home visits, but also billed for additional
time, prolonging the home visits past the highest level, for more than half of the visits.
More than 320 providers billed for telehealth services for more
than 300 days of the year
A total of 328 providers billed for telehealth services for more than 300 days of the
year, which averages to more than 25 days per month for each provider. Each of
these providers billed for telehealth services for many more days, compared to the
median of 26 days of the year for all providers who billed for telehealth services.
Billing for telehealth for a high number of days may indicate that the provider may
not be providing the services for which they are billing. The 328 providers who billed
for telehealth services for more than 300 days received a total of $65 million in
Medicare fee-for-service payments. In some cases, these providers were concentrated
in specific medical practices. Specifically, 96 of the 328 providers are a part of the
same medical practice as at least one other provider who billed for more than 300
days.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Results | 8
Example of providers who billed for telehealth services for more than 300
days of the year
Two family medicine providers billed for telehealth services every single day from
March 1, 2020, to February 28, 2021. Together, they billed for nearly 18,600
services for slightly more than 1,800 beneficiaries—averaging to more than 10
services for each beneficiary. They received nearly $500,000 in Medicare fee-for-
service payments.
Two other providers—who appear to be associated with the same telehealth
company—billed for telehealth services every single day of the year. Together,
these providers billed for approximately 76,000 services for slightly more than
4,300 beneficiaries—averaging to more than 17 services for each beneficiary. They
received more than $1.4 million in Medicare fee-for-service payments.
More than 130 providers repeatedly billed Medicare fee-for-
service and a Medicare Advantage plan for the same telehealth
service
A total of 138 providers billed both Medicare fee-for-service and a Medicare
Advantage plan for the same telehealth service for more than 20 percent of their
telehealth services. 21 Repeatedly billing both Medicare programs for the same service
may indicate that providers are intentionally submitting duplicate claims to increase
their Medicare payments.
These 138 providers billed both programs for more than 9,000 telehealth services. Of
note, three providers billed both Medicare fee-for-service and a Medicare Advantage
plan for at least 90 percent of their telehealth services.
More than 80 providers billed for a high average number of
hours of telehealth services per visit
In total, 86 providers billed for an average of more than 2 hours of telehealth services
per visit. This is far higher than the median of 21 minutes of telehealth services per
visit for all providers who billed for telehealth services.
When providers bill for a high average number of hours of telehealth services per
visit, they may be billing for unnecessary services or for services not rendered. 22 This
is one method that unscrupulous providers use to inappropriately maximize their
Medicare payments. 23
Notably, 10 providers billed an average of 3 or more hours per visit—more than 8
times the average for a telehealth visit. One provider, a psychologist, billed 3 or more
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Results | 9
hours for more than 150 visits. On one occasion, this provider billed for 10 hours for
a single visit for one beneficiary.
Many of the providers who billed for a high average number of hours of telehealth
services per visit billed for the same service multiple times during a single visit. These
providers commonly billed for multiple psychotherapy or rehabilitation sessions for
the same patient in a single day. For example, nine providers each billed five or more
times for psychotherapy for several visits. This may indicate that these providers are
inappropriately maximizing Medicare payments by billing for services not provided or
providing unnecessary services.
Example of a provider who billed for a high number of hours of telehealth
services per visit
One mental health counselor billed an average of nearly 4 hours per visit for 37
different visits. This provider also frequently billed the same psychotherapy
service eight times per visit. This provider and six other providers who billed a
high number of hours worked for the same chain of mental health and substance
use recovery facilities in Florida.
More than 70 providers billed for telehealth services for a high
number of beneficiaries
These 76 providers each billed for telehealth services for at least 2,000 beneficiaries in
a year. This is far above the median of 21 beneficiaries for all providers who billed for
telehealth services. These providers billed for more than 1.7 million telehealth
services, totaling nearly $57.5 million in Medicare fee-for-service payments. They
most commonly billed for office visits and audio-only services.
Two of these providers, who appear to be associated with the same telehealth
company, each billed for more than 10,000 beneficiaries. One of these providers
billed for more than 27,400 beneficiaries—an average of 75 beneficiaries a day if the
provider rendered services every single day for a year. Another provider, who did not
appear to be associated with a telehealth company, billed for more than 4,400
beneficiaries. For this to occur, this provider would need to see an average of 12 new
beneficiaries every single day for a year.
It is highly improbable that these providers rendered telehealth services to, or were
available to supervise telehealth services for, so many beneficiaries. Billing for a high
number of beneficiaries may indicate that the provider is billing for services that were
not provided. If these services were provided, this billing raises serious concerns
about the quality of care.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
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In total, six medical practices were associated with multiple providers who billed for a
high number of beneficiaries. In one case, six providers were a part of the same
medical practice.
More than 60 providers commonly billed for telehealth services
and then ordered medical equipment and supplies
In total, 67 providers billed for telehealth services and then ordered medical
equipment and supplies for at least half of their beneficiaries. This is far higher than
the median of 3 percent for all providers. 24 Billing medical equipment and supplies
for a high percentage of beneficiaries raises concern, as this practice has been linked
to known fraud schemes.
In total, these 67 providers billed for telehealth services and ordered medical
equipment and supplies that amounted to a total of more than $28 million from
Medicare fee-for-service. These providers may be ordering unnecessary medical
equipment and supplies for beneficiaries. For example, providers may be billing for
telehealth services, regardless of whether a beneficiary was ever contacted, and
ordering medical equipment and supplies as part of a kickback scheme with suppliers.
Of note, most of these providers specialized in internal or family medicine.
There is added concern when providers order medical equipment and supplies
primarily for beneficiaries with whom they do not have an established relationship.
During the pandemic, the requirement for an in-person visit with the beneficiary
before ordering medical equipment and supplies was waived in most instances. 25
Notably, seven providers ordered medical equipment and supplies solely for
beneficiaries with whom they had no established relationship. This billing pattern
may indicate that these providers are billing for telehealth services and ordering
medical equipment and supplies using stolen or compromised beneficiary identifiers.
Additionally, six providers billed primarily for audio-only telehealth services before
ordering medical equipment and supplies for beneficiaries. This may indicate that
providers are cold calling new beneficiaries to increase orders for medical equipment,
supplies, and telehealth services. 26 In 2021 and 2022, OIG and other law enforcement
partners uncovered alleged kickback schemes that involved telehealth companies
partnering with durable medical equipment companies to commit Medicare fraud.27
In some instances, the providers allegedly billed Medicare for telehealth services that
did not occur.
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Examples of providers who billed for telehealth services and then ordered
medical equipment and supplies
One physician billed for telehealth and then ordered medical equipment and
supplies for more than 400 beneficiaries, representing nearly 78 percent of their
beneficiaries. This physician ordered 109 different types of medical equipment and
supplies, totaling more than $9 million. The physician did not have an established
relationship with any of the 400 beneficiaries and appeared to provide services
through a telehealth company.
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CONCLUSION AND RECOMMENDATIONS
The changes to Medicare telehealth policy, along with the dramatic increase in the
use of telehealth, underscore the importance of determining whether providers are
billing for telehealth services appropriately and of identifying ways to safeguard the
program against fraud, waste, and abuse.
We identified 1,714 providers whose billing for telehealth services during the first year
of the pandemic poses a high risk to Medicare. Although these providers represent a
small proportion of the approximately 742,000 providers who billed for a telehealth
service, their billing raises concern. For example, they may be billing for telehealth
services that are not medically necessary or were never provided.
These findings also highlight several ways that providers may inappropriately bill for
telehealth services. Further, these findings shed light on potential methods for
safeguarding the program and protecting beneficiaries specific to telehealth.
As permanent changes to telehealth are considered, it is essential that CMS, Congress,
and other stakeholders incorporate targeted, appropriate safeguards to prevent,
detect, and remediate the program integrity risks identified in this report. Currently,
CMS is utilizing existing tools, such as pre- and post-payment edits and the Fraud
Prevention System edits, to address program integrity risks associated with telehealth.
Additionally, CMS is part of the Healthcare Fraud Prevention Partnership and meets
with OIG investigators and the Department of Justice (DOJ) to discuss fraud trends
and coordinate on certain cases of suspected fraud. 28 CMS also conducts provider
interviews, beneficiary interviews, and medical reviews to determine whether services
billed were medically necessary. However, the billing practices that we identified
demonstrate the benefit and importance of strengthening targeted oversight of
telehealth services to protect the Medicare program and beneficiaries against fraud,
waste, and abuse. 29
We recommend that CMS:
Strengthen monitoring and targeted oversight of telehealth
services
To effectively target program integrity efforts, CMS and its contractors should closely
monitor telehealth services on an ongoing basis to identify providers who pose a risk
to the program. CMS could use the measures in this report, and others it deems
appropriate, when designing its claims analysis to strengthen its oversight of
telehealth services. Further, as program integrity risks evolve, stakeholders can use
these findings to inform future oversight efforts.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Conclusion and Recommendations | 13
In addition, CMS currently sends reports to select providers that compare their
number of claims for certain telehealth services to national and State averages. 30
CMS could incorporate additional measures into these provider reports based on the
program integrity risks identified in this report. For example, it could include
measures that focus on the extent to which providers bill for the highest, most
expensive levels of certain telehealth services.
CMS should also conduct targeted reviews of providers identified through the
measures we developed, or others it deems appropriate. These reviews could include
close monitoring of providers’ billing patterns and reviews of their medical records, as
appropriate. These reviews could be used to recover inappropriate payments, to
place certain providers on prepayment review, to initiate fraud investigations, or to
develop additional claims processing edits, as necessary.
Provide additional education to providers on appropriate billing
for telehealth services
The providers identified in this report billed in a manner that may indicate fraud,
waste, or abuse. In addition to these providers, other providers billed for telehealth
services inappropriately but did not exceed the high thresholds we set for these
measures. For example, more than 18,000 providers billed both Medicare fee-for-
service and a Medicare Advantage plan for the same telehealth service at least once.
Additionally, more than 5,700 providers billed for both a telehealth service and a
facility fee for the same visit at least once. One way to reduce inappropriate billing is
to provide additional education to providers on how to correctly bill for telehealth
services.
CMS should conduct additional educational outreach to providers. CMS should offer
additional trainings and webinars on how to appropriately bill for telehealth services
through its Medicare Learning Network. As a part of this outreach, CMS should
include information such as when it is appropriate to bill an originating site facility fee
and how to avoid billing Medicare fee-for-service and a Medicare Advantage plan for
the same service.
Further, CMS should target specific providers with high levels of inappropriate billing
for telehealth services and provide one-on-one education to them. These one-on-
one training sessions should include a discussion with the provider about the
telehealth services inappropriately billed and a review of CMS guidelines that should
have been followed.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Conclusion and Recommendations | 14
Improve the transparency of “incident to” services when clinical
staff primarily delivered a telehealth service
Identifying the individual who delivered the telehealth service that is billed to
Medicare is critical to program integrity efforts; however, this identification is not
possible under Medicare’s current billing rules. “Incident to” billing allows services
provided by clinical staff who are directly supervised by a physician or non-physician
practitioner to be billed under the supervising practitioner’s identification number.
Consequently, multiple individuals can provide telehealth services under a single
identification number. This billing practice makes it difficult to determine when
telehealth services were provided by the physician or when services were rendered
“incident to” a physician.
Further, Medicare billing data would also not reveal whether an individual providing a
service under a physician’s supervision had been terminated from Medicare or
excluded from participation from Federal health care programs. In addition, prior OIG
work found that “incident to” services provided in person were frequently delivered
by practitioners who lacked the licenses, certifications, credentials, or training required
for those services. 31 It is important that CMS and oversight agencies are able to
determine which provider rendered a telehealth service to a beneficiary.
For this reason, CMS should require the use of a modifier to indicate “incident to”
telehealth services when clinical staff primarily delivered the service billed under the
supervising practitioner’s identification number. To do so, CMS should create a
service code modifier. CMS should require that providers use this modifier on
Medicare fee-for-service claims and Medicare Advantage encounters to identify
“incident to” telehealth services.
In addition to the modifier, CMS should also take steps to allow providers to report
the identification number of the clinical staff who primarily delivered the service, when
available. 32 To do so, CMS should take steps to create a new field for clinical staff
who have their own identification number to report this information. CMS should
work with the designated standards development organization (X12) and the National
Uniform Claim Committee to initiate this change on the claim form. Taking these
steps would allow CMS to require providers to complete this field with the clinical
staff’s identification number for both Medicare fee-for-service claims and Medicare
Advantage encounters.
By taking these steps to increase transparency, CMS can strengthen program integrity
efforts and enable oversight agencies to conduct more detailed analyses at the
provider level. This information can also be used to help monitor quality of care and
beneficiary safety related to the use of remote supervision. 33
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Conclusion and Recommendations | 15
Identify telehealth companies that bill Medicare
Some of the providers we identified who pose 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. To improve oversight of telehealth services, it
is important that CMS and other oversight agencies be able to identify providers
associated with telehealth companies on claims and encounters. CMS and others
could use this information to more closely monitor these companies and identify
companies that pose a risk to the Medicare program.
CMS should identify telehealth companies that bill Medicare. To do this, CMS could
update the Medicare provider enrollment application (e.g., CMS-855B) to identify
telehealth companies that enroll in Medicare. Alternatively, CMS could work with the
National Uniform Claim Committee to add a taxonomy code that identifies telehealth
companies. This information would allow CMS to monitor when beneficiaries receive
services from providers associated with telehealth companies and could assist quality
of care assessments in the future. The Medicare Payment Advisory Commission has
noted concerns that if beneficiaries receive services via telehealth companies from
clinicians who are not their usual source of care, their care may become fragmented. 34
It has also noted the need to identify telehealth companies to assess appropriate
reimbursement for services provided by telehealth companies. 35
Follow up on the providers identified in this report
In a separate memorandum, we will refer to CMS the providers we identified as
posing a high risk to Medicare. CMS should review this information and take action,
as appropriate.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Conclusion and Recommendations | 16
AGENCY COMMENTS AND OIG RESPONSE
CMS concurred with our recommendation to follow up on the providers identified in
this report, but CMS did not explicitly indicate whether it concurred with the other
four recommendations.
CMS did not explicitly indicate whether it concurred with our recommendation to
strengthen monitoring and targeted oversight of telehealth services. CMS stated that
it will need to carefully review the issues identified to assess whether these issues
have already been addressed, and if not, whether additional CMS actions are needed.
In response, OIG emphasizes that this report highlights several ways that providers
may be inappropriately billing for telehealth services and sheds light on potential
methods specific to telehealth for safeguarding the program and protecting
beneficiaries. Accordingly, we encourage CMS to strengthen targeted oversight of
telehealth services to protect the Medicare program and beneficiaries against fraud,
waste, and abuse. While OIG recognizes that the providers identified in this report
represent a small percentage of the overall number of Medicare providers who billed
for a telehealth service during the first year of the pandemic, that also means that
targeted oversight of specific providers may be especially effective in addressing
potential fraud, waste, and abuse related to telehealth services. Additionally, because
this data brief focuses on specific measures with very high thresholds, it does not
capture all concerning billing related to telehealth services that may be occurring in
Medicare. Strengthening monitoring and targeted oversight could help prevent the
number of high-risk providers from increasing in the future.
CMS also did not explicitly indicate whether it concurred with our recommendation to
provide additional education to providers on appropriate billing for telehealth
services. CMS noted that it has provided a variety of educational materials to
promote proper billing for telehealth services and that it provides one-on-one
education when appropriate and cost effective. CMS stated that it will analyze OIG’s
data to determine whether additional education is necessary. In response, OIG
emphasizes that providing additional education to providers on how to correctly bill
for telehealth services is one way to reduce inappropriate billing. We appreciate that
CMS has taken some steps toward this recommendation and encourage it to further
build on those steps. For example, while CMS has provided information on the
location requirements for originating sites in a Medicare Learning Network Fact Sheet
on telehealth services, providing additional education on when providers may or may
not bill for the originating site facility fee can help reduce improper billing and
payments. 36 We further note that many providers billed for telehealth services
inappropriately but did not exceed the high thresholds we set for these measures.
CMS also did not explicitly indicate whether it concurred with our recommendation to
improve the transparency of “incident to” services when clinical staff primarily
delivered a telehealth service. CMS acknowledged that increasing transparency of
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Agency Comments and OIG Response | 17
“incident to” services could aid in program integrity efforts. However, CMS stated
that modifying the claim form to add a new field is not within the Agency’s control
and requires extensive system changes that may impact the entire health care system.
CMS further stated that it does not believe that a modifier is sufficient to address
OIG’s concerns without a change to the claim form to identify the individual who
primarily delivered the service. In response, OIG continues to emphasize the
importance of CMS and oversight agencies having the ability to determine which
provider rendered a telehealth service to a beneficiary. Accordingly, while OIG
recognizes that modifying the claim form will take time and poses a significant
undertaking, the need for increased transparency is important. As a critical partner
with multiple representatives on the National Uniform Claim Committee, we
encourage CMS to pursue the steps listed in this report to modify the claim form. In
the meantime, OIG encourages CMS to use its authority to create a service code
modifier to identify “incident to” services when clinical staff primarily delivered the
service billed under a supervising practitioner’s identification number.
CMS also did not explicitly indicate whether it concurred with our recommendation to
identify telehealth companies that bill Medicare. CMS stated that it has developed
ways to assist with identifying telehealth companies and providers associated with
telehealth companies. CMS noted that if it finds additional information is necessary it
will evaluate the feasibility and benefits of modifying the provider enrollment
application and/or adding a taxonomy code to identify telehealth companies. In
response, OIG emphasizes that the findings of this report highlight the importance of
CMS and other oversight agencies being able to identify providers associated with
telehealth companies on claims and encounters to improve oversight of telehealth
services.
CMS concurred with our recommendation to follow up on the providers identified in
this report. CMS stated that it will review the providers identified as posing a high risk
to Medicare and will follow up as appropriate.
We ask that CMS—in its Final Management Decision—provide details on any plans
and progress toward implementing our recommendations.
For the full text of CMS’s comments, see Appendix C.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Agency Comments and OIG Response | 18
METHODOLOGY
We based this data brief on an analysis of Medicare fee-for-service claims data and
Medicare Advantage encounter data. We included Medicare claims from Medicare
fee-for-service and encounters from Medicare Advantage plans from March 1, 2020,
to February 28, 2021. These data are similar to the data used in other reports in the
series about Medicare beneficiaries’ use of telehealth during the pandemic. 37
We used the Medicare Part B fee-for-service claims from the National Claims History
File and Medicare Advantage encounters from Part C Encounter data. We included
telehealth services billed by individual practitioners; we did not include telehealth
services billed by institutional entities, such as hospitals and nursing homes. We
included claims and encounters that were “final action” and approved for payment.
We used provider enrollment data from the National Plan and Provider Enumeration
System. 38
Analysis of Providers Who Billed for Telehealth Services
To conduct this analysis, we first identified the services that Medicare approved for
telehealth during the pandemic. 39 These services can be provided via telehealth or in
person. These services are identified using Current Procedural Terminology (CPT)
codes and Healthcare Common Procedure Coding System (HCPCS) codes. These
codes are included on the claim by a provider for reimbursement purposes.
Our analysis included virtual care services as a type of telehealth service. These
services are also referred to as communication technology-based services. These
services are always provided remotely, and include virtual check-ins, e-visits, remote
monitoring, and telephone calls with a provider to discuss a beneficiary’s medical
condition.
We identified other services that were provided via telehealth using a modifier (i.e.,
95, GT, GQ, or G0) or a place of service code (i.e., 02) that indicates the service was
delivered via telehealth. 40
Next, we identified providers who billed Medicare for telehealth services. These are
the providers identified on the claims and encounter data as rendering the service.
We included individual providers such as physicians and non-physician practitioners
who billed either Medicare fee-for-service, Medicare Advantage plans, or both. 41
Program Integrity Measures
To identify providers who pose a high risk to Medicare, we developed seven measures
as indicators of possible fraud, waste, or abuse. These measures focus on different
types of billing for telehealth that providers may use to maximize their Medicare
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OEI-02-20-00720 Methodology | 19
payments. We developed these measures based on analyses of Medicare data and
input from OIG investigators.
In total, we identified 741,759 providers who billed for a telehealth service during the
pandemic. For each provider, we analyzed the telehealth services they billed to
Medicare. For each measure, we developed thresholds that may indicate possible
fraud, waste, or abuse. All of the thresholds reflect extreme levels—they are all higher
than thresholds based on a standard technique to identify outliers, known as the
Tukey method. 42
For each provider, we calculated the following measures:
1. Billing for both a telehealth service and a facility fee for the majority of visits
For each provider, we determined the percentage of visits that included both an
originating site facility fee and a telehealth service. 43 We identified providers who
billed both an originating site facility fee and a telehealth service for more than
75 percent of their visits; most providers never billed this way.
2. Billing telehealth services at the highest, most expensive level every time
For each provider, we calculated the percentage of telehealth services billed at the
highest level for the following services: (1) office visits, (2) nursing home visits, (3)
assisted living visits, and (4) home visits. 44 We identified providers who always billed
for telehealth services at the highest level for each of these types of services; most
providers rarely, if ever, billed at the highest level.
We also determined the percentage of services that were prolonged (i.e., a duration of
time spent beyond the maximum time for the highest level of service).
3. Billing telehealth services for a high number of days
For each provider, we determined the total number of days worked during the 1-year
timeframe of our analysis. We identified providers who billed telehealth services for
more than 300 days—far higher than the median of 26 days. Billing for more than
300 days in a year averages to more than 25 days a month for each provider.
4. Billing both Medicare fee-for-service and a Medicare Advantage plan for the
same service for a high proportion of services
For each provider, we calculated the percentage of services that were billed to both
Medicare fee-for-service and a Medicare Advantage plan for the same telehealth
service for the same beneficiary on the same date of service.45 We identified
providers who billed both Medicare fee-for-service and a Medicare Advantage plan
for the same service for more than 20 percent of their services; most providers never
billed this way.
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OEI-02-20-00720 Methodology | 20
5. Billing a high average number of hours of telehealth services per visit
For each provider, we calculated the average number of hours of telehealth service
provided per visit. 46 We identified providers who billed more than an average of
2 hours per visit—far higher than the median of 21 minutes.
6. Billing telehealth services for a high number of beneficiaries
For each provider, we calculated the number of beneficiaries for whom they had billed
a telehealth service. We identified providers who billed telehealth services for 2,000
or more beneficiaries—far higher than the median of 21 beneficiaries. 47
7. Billing for a telehealth service and ordering medical equipment for many of
their beneficiaries
For each provider, we calculated the percentage of beneficiaries for whom they had
billed a telehealth service and then ordered medical equipment and supplies. 48 We
focused this analysis on durable medical equipment and components, accessories,
and supplies; orthotics and services; and prosthetics that were billed within 3 months
of the telehealth service. We identified providers who billed for a telehealth service
and ordered medical equipment and supplies for at least half of their beneficiaries—
far higher than the median of 3 percent of beneficiaries.
Additionally, for each provider, we focused on the beneficiaries for whom they had
ordered medical equipment and supplies and calculated the percentage of these
beneficiaries for whom the provider did not have an established relationship. To
determine whether a beneficiary had an established relationship with a provider, we
identified the date of the first telehealth service with the provider and looked back to
January 2018 to determine whether the beneficiary had a prior in-person visit or other
service with that same provider (i.e., providers in the same medical practice).
In addition, for each provider, we focused on the beneficiaries for whom they had
ordered medical equipment and supplies and calculated the percentage of these
beneficiaries’ services that were provided audio-only. 49
Analysis of Providers Whose Billing Poses a High Risk
We identified the providers who exceeded the threshold on at least one of seven
measures. These are providers whose billing is concerning and poses a high risk to
Medicare.
As a next step, we determined whether the providers we identified based on the
measures described above had certain characteristics in common. We looked at the
most common services billed and instances where providers are a part of the same
medical practice. 50
In addition, we identified providers who appear to be associated with telehealth
companies by reviewing the name of the provider billing Medicare. However, there is
currently no systematic way to identify these companies in the Medicare data.
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OEI-02-20-00720 Methodology | 21
Limitations
We designed this study to identify telehealth providers who warrant further scrutiny.
None of the measures that we analyzed confirm that a particular provider is engaging
in fraudulent or abusive practices. Any determination of fraud or an overpayment
would require additional investigation. Further, because we could not identify
“incident to” billing, we were unable to include certain measures that could have
captured additional fraud, waste, and abuse that may be occurring. For example, we
could not identify providers who were billing for more than 24 hours in a day.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
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OEI-02-20-00720 Methodology | 22
APPENDIX A
Examples of Medicare Telehealth Services
Office Visits Virtual Care Services Behavioral Health Nursing Home Visits
Routine appointment Telephone call to Services Visit from a provider
with a primary care discuss a beneficiary's Individual therapy with a beneficiary
provider or specialist medical condition Group therapy located in a nursing
Online interactions via home
Substance use disorder
a patient portal treatment Remote assistance with
Remote monitoring of the use of a ventilator
vital statistics
Preventive Services Physical, Home Visits Hospital Visits
Annual wellness visit Occupational, and Visit from a provider Hospital observation or
Speech Therapy Visits with a beneficiary inpatient care
Diabetes management
training Wheelchair located at home Emergency department
management Evaluation of ventilator visit
Medical nutrition
therapy Training in use of use for a beneficiary Critical care
prosthesis receiving respiratory consultation
Tobacco use care at home
counseling Evaluation of speech
fluency
Assisted Living Visits Transitional Care Dialysis Services Advanced Care
Visit from a provider Services End-stage renal Planning Services
with a beneficiary Communication with disease related Explanation and
located in an assisted beneficiary or caregiver services, such as discussion of advance
living facility after discharge from monitoring of nutrition directives with a
hospital and counseling beneficiary and/or
family member
Ophthalmology Other Services
Services Radiation treatment
Eye examination and management
evaluation Evaluation of inhaler
use
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Appendix A | 23
APPENDIX B
Billing for Various Levels of Complexity and Duration
Office Visits Established
New Patient
Visit Patient Visit
Office visits represented
48 percent of all services
provided via telehealth • 10 min $37 • 5 min $16
during the pandemic. 51 • 20 min $64 • 10 min $36
These visits include • 30 min $93 • 15 min $64
services with primary care • 45 min $150 • 25 min $95
providers and specialists • 60 min $192 • 40 min $131
for the purpose of
evaluating or managing
the beneficiary’s medical condition. The payment amount for the highest complexity
level for new patients is five times the amount for the lowest complexity level. For
established patients, it is almost eight times the amount.
Nursing Home Visits Subsequent
Initial Nursing
Home Visit Visit
In the first 30 days after a
beneficiary’s admission,
Medicare requires a • 25 min $92 • 10 min $45
physician to conduct an • 35 min $132 • 15 min $70
initial visit to assess the
• 45 min $170 • 25 min $93
beneficiary’s condition,
• 35 min $137
develop a plan of care,
and write or verify their
admitting orders. 52
Medicare also requires periodic physician visits to monitor and evaluate nursing
facility residents during their stay. 53 In addition, Medicare will cover physician visits
outside of the periodic checks that are deemed medically necessary.54
Initial nursing facility visits can range in duration from 25 to 45 minutes. Subsequent
nursing facility visits can range in duration from 10 to 35 minutes. The payment
amount for the highest complexity level for initial visits is nearly double the amount
for the lowest complexity level. For subsequent visits, it is about three times the
amount.
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OEI-02-20-00720 Appendix B | 24
Assisted Living Visits
Medicare covers visits by Established
New Patient
providers to oversee or Visit Patient Visit
directly provide beneficiaries
with examinations and medical
• 20 min $56 • 15 min $61
counseling in an assisted living
• 30 min $81 • 25 min $97
setting. 55 These visits must be
medically necessary and an • 45 min $141 • 40 min $137
extension of normal • 60 min $190 • 60 min $198
beneficiary care. Assisted
56
• 75 min $224
living visits for new patients
can range in duration from 20 to 75 minutes. Assisted living visits for established
patients can range in duration from 15 to 60 minutes. The payment amount for the
highest complexity level for a new patient assisted living visit is four times the amount
for the lowest complexity level. For established patients it is three times the amount.
Home Visits
A home visit is an evaluation
and management service New Patient Established
provided by a physician to a Visit Patient Visit
beneficiary in their private
residence. Unlike with home • 20 min $56 • 15 min $56
health services, the beneficiary • 30 min $80 • 25 min $86
does not need to be confined • 45 min $131 • 40 min $131
to their home to receive a • 60 min $186 • 60 min $183
home visit. Home visits for
• 75 min $226
new patients can range in
duration from 20 to 75
minutes. Home visits for established patients can range in duration from 15 to
60 minutes. The payment amount for the highest complexity level for new patients is
four times the amount for the lowest complexity level. For established patients, it is
about three times the amount.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Appendix B | 25
DATE: July 29, 2022
TO: Gregory E. Demske
Acting Principal Deputy Inspector General
Office of Inspector General
FROM: Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
SUBJECT: Office of Inspector General (OIG) Draft Data Brief: Medicare Telehealth Services
During the First Year of the Pandemic: Program Integrity Risks (OEI-02-20-
00720)
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the Office of Inspector General’s (OIG) draft report.
CMS serves the public as a trusted partner and steward, dedicated to advancing health equity,
expanding coverage, and improving health outcomes. Consistent with these goals, CMS issued
waivers to prevent gaps in access to care for patients affected by the COVID-19 public health
emergency (PHE), including waivers for services furnished via telehealth. The changes to
payment and coverage policies were intended to allow health care providers maximum flexibility
to minimize the spread of COVID-19 among Medicare beneficiaries, health care personnel, and
the community at large and increase capacity to address the needs of their patients.
On March 17, 2020, CMS announced the expansion of telehealth services on a temporary and
emergency basis pursuant to waiver authority added under section 1135(b)(8) of the Social
Security Act by the Coronavirus Preparedness and Response Supplemental Appropriations Act,
2020 (Pub. L. 116-123, March 6, 2020). Beginning on March 6, 2020, and for the duration of the
COVID-19 PHE, Medicare pays for telehealth services, including office, hospital, and other
visits furnished by physicians and other practitioners to patients located anywhere in the country,
including in a patient’s place of residence. In the context of the COVID-19 PHE, CMS
recognized that the use of telehealth could help address new challenges regarding potential
exposure risks, for people with Medicare, health care providers, the community at large. To
facilitate the use of telecommunications technology as a safe substitute for in-person services,
CMS, on a temporary interim final basis, added many services to the list of eligible Medicare
telehealth services, eliminated frequency limitations and other requirements associated with
particular services furnished via telehealth, and clarified several payment rules that apply to other
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Agency Comments B | 26
services that are furnished using telecommunications technologies that can reduce exposure
risks. 1
CMS recognizes the importance of analyzing the impact of these changes, and, as such,
immediately evaluated the waivers and flexibilities issued by the Agency to determine the
potential for fraud, waste, and abuse in the Medicare program. This process included identifying
program integrity risks and vulnerabilities associated with the waivers and flexibilities;
prioritizing those with the largest potential for financial loss, beneficiary harm and/or likelihood
of occurrence; and creating mitigations that addressed these program integrity risks and
vulnerabilities, including those related to telehealth.
One such mitigation strategy has been the continued use of data analytics to identify potential
program integrity risks. CMS has continued throughout the PHE to analyze claims data to
monitor, trend, and respond to existing telehealth fraud schemes and to detect and respond to
potential new emerging fraud schemes. CMS uses a robust program integrity strategy to reduce
and prevent Medicare improper payments, which includes the use of the Fraud Prevention
System (FPS). The FPS is a predictive analytics technology that runs sophisticated algorithms
against Medicare Fee-For Service (FFS) claims nationwide. When FPS models identify aberrant
activity or patterns, the system automatically generates and prioritizes leads for further review
and investigation by Unified Program Integrity Contractors (UPICs). Based on the results of all
information collected, the UPICs coordinate with CMS and the Medicare Administrative
Contractors in taking appropriate administrative action to recover improper payments and
prevent future loss of funds, or the UPICs refer the case to law enforcement.
Additionally, CMS has supported our federal law enforcement partners throughout the PHE on
various fraud schemes including those related to telehealth. CMS continues to meet regularly
with law enforcement to discuss new cases, fraud referrals, active UPIC and law enforcement
cases, and paths for various administrative actions.
CMS has also taken action to prevent improper Medicare payments by educating health care
providers and suppliers on proper billing. For example, CMS has undertaken a number of
stakeholder calls including open door forums and Medicare Learning Network calls, as well as
published numerous pieces of subregulatory guidance designed to educate practitioners on the
additional telehealth flexibilities, including how to appropriately bill for these services. 2
The OIG’s recommendations and CMS’ responses are below.
OIG Recommendation
The OIG recommends that CMS strengthen monitoring and targeted oversight of telehealth
services.
1
The list of these eligible telehealth services is published on the CMS website at
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html.
2
Open Door Forum Podcast and Transcripts available at: https://www.cms.gov/Outreach-and-
Education/Outreach/OpenDoorForums/PodcastAndTranscripts; COVID-19 Frequently Asked Questions (FAQs) on
Medicare Fee-For-Service (FFS) Billing available at: https://www.cms.gov/files/document/03092020-covid-19-faqs-
508.pdf; Physician Fee Schedule Proposed Rule: Understanding 4 Key Topics Listening Session, August, 13, 2020.
Available at: https://www.cms.gov/outreach-and-educationoutreachnpcnational-provider-calls-and-events/2020-08-
13; CMS.gov Current Emergencies webpage available at: https://www.cms.gov/About-CMS/Agency-
Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
Agency Comments B | 27
OEI-02-20-00720
CMS Response
The providers identified by the OIG and their total associated Medicare FFS payments represent
a small portion of the services furnished via telehealth during the first year of the PHE—
representing approximately two tenths of a percent of all providers who billed for telehealth and
approximately 2.5 percent of all Medicare FFS payments for telehealth services. While these are
relatively small percentages, CMS takes these findings seriously and appreciates the OIG’s
review in this area. Given that this report was conducted outside of CMS’s and law enforcement
entities’ program integrity efforts, CMS will need to carefully review the issues identified to
assess whether these issues have already been addressed, and if not, whether additional CMS
actions are needed. CMS looks forward to receiving details on these issues.
CMS will review the providers identified as posing a high risk to Medicare against those
telehealth providers already identified by CMS and within the context of the larger program
integrity strategy, and determine whether any additional monitoring or oversight of telehealth
services is necessary.
OIG Recommendation
The OIG recommends that CMS provide additional education to providers on appropriate billing
for telehealth services.
CMS Response
As stated above, CMS has provided a variety of educational materials to promote proper billing
for telehealth services. OIG specifically states that CMS should include information such as
when it is appropriate to bill an originating site facility fee and how to avoid billing Medicare
FFS and a Medicare Advantage plan for the same service. CMS has provided information on the
requirements for originating sites as well as how to check Medicare eligibility which shows
whether a beneficiary is enrolled in a Medicare Advantage plan, to facilitate proper submission
of claims.3, 4 OIG also suggests that CMS should target specific providers with high levels of
inappropriate billing for telehealth services and provide one-on-one education to them. CMS
provides one-on-one education when appropriate and cost effective. CMS will analyze OIG’s
data and determine whether additional education, including one-on-one education, is necessary.
OIG Recommendation
The OIG recommends that CMS improve the transparency of “incident to” services when
clinical staff primarily delivered a telehealth service.
CMS Response
CMS acknowledges that increasing transparency of “incident to” services could aid in program
integrity efforts; however, modifying the claim form to add a new field is not within the
Agency’s control. As mentioned in the full recommendation in the report, modification of the
claim form is a function of the designated standards maintenance organization. Modifications to
the claim form are a significant undertaking and require extensive system changes that impact
the entire healthcare system. Therefore, this process requires industry consensus and is not based
strictly on Medicare need or preference.
3
Medicate Learning Network (MLN) Fact Sheet: Telehealth Services (June 2021) available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf
4
MLN Fact Sheet: Checking Medicare Eligibility (October 2021) available at:
https://www.cms.gov/files/document/checking-medicare-eligibility.pdf
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
Agency Comments B | 28
OEI-02-20-00720
OIG also suggests that CMS require a modifier to indicate “incident to” telehealth services. CMS
does not believe that a modifier is sufficient to address the OIG’s concerns without the change to
the claim form to identify the individual who primarily delivered the service.
OIG Recommendation
The OIG recommends that CMS identify telehealth companies that bill for Medicare.
CMS Response
Based on the OIG’s findings, the risk associated with telehealth companies is unclear. As stated
above, CMS has a robust program integrity strategy. As part of this strategy, CMS has developed
ways to assist with identifying telehealth companies and providers associated with telehealth
companies. Consistent with Recommendation 5 below, CMS will review the providers identified
as posing a high risk to Medicare against those telehealth providers already identified by CMS,
and within the context of the larger program integrity strategy, and determine whether additional
information is necessary to identify telehealth companies. If additional information is necessary,
CMS will evaluate the feasibility and benefits of modifying the provider enrollment application
and/or adding a taxonomy code to identify telehealth companies.
OIG Recommendation
The OIG recommends that CMS follow up on the providers identified in the report.
CMS Response
CMS concurs with this recommendation. CMS will review the providers identified as posing a high
risk to Medicare against those telehealth providers already identified by CMS, and within the
context of the larger program integrity strategy. If necessary, CMS will follow up as determined
appropriate.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Agency Comments B | 29
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Judy Kellis served as the team leader for this study. Others in the Office of Evaluation
and Inspections who conducted the study include Alexis Mills and John Gordon.
Office of Evaluation and Inspections staff who contributed to the study include Miriam
Anderson, Robert Gibbons, Eddie Baker, Jr., and Michael Novello.
This report was prepared under the direction of Jodi Nudelman, Regional Inspector
General for Evaluation and Inspections in the New York regional office, and Nancy
Harrison and Meridith Seife, Deputy Regional Inspectors General.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Acknowledgments and Contact | 30
ENDNOTES
1 HHS and CMS were able to temporarily expand access to telehealth because of their waiver authority under section 1135 of
the Social Security Act, subsequent legislation, and the Secretary’s declaration of a public health emergency due to COVID-19.
The public health emergency was announced on January 31, 2020. See HHS, Determination that a Public Health Emergency
Exists, January 31, 2020, accessed at https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx on April
8, 2022. See also Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, accessed at
https://www.congress.gov/bill/116th-congress/house-bill/6074/text/rds on November 23, 2021. See also Families First
Coronavirus Response Act, accessed at https://www.congress.gov/bill/116th-congress/house-bill/6201/text on April 15, 2022.
See also CARES Act, accessed at https://www.congress.gov/bill/116th-congress/house-bill/748/text on November 23, 2021.
2 CMS, Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs), July 2020. Accessed at
https://www.cms.gov/files/document/provider-burden-relief-
faqs.pdf#:~:text=On%20March%2030%20CMS%20suspended%20most%20Medicare%20Fee-For-
Service,potentially%20selected%20for%20review%20will%20also%20be%20applied on December 28, 2021.
3 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 2022.
4 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established
relationship, OEI-02-20-00521, October 2021; OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries
During the First Year of the COVID-19 Pandemic, OEI-02-20-00520, March 2022; OIG, 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, OEI-02-20-00522, September 2022; Pandemic Response Accountability Committee, Telehealth Services in Select
Federal Health Care Programs, forthcoming.
5 For the purposes of this report, we refer to the services that can be delivered either via telehealth or in-person—as well as
services that are always provided remotely—as telehealth services.
6 These services are also referred to as communication technology-based services.
For the purposes of this report, we refer to
them as virtual care services. CMS does not include communication technology-based services in its formal definition of
telehealth services.
7 For example, prior to the pandemic, beneficiaries were allowed to use telehealth services to address substance use disorder
or end-stage renal disease from their home and in urban areas. In addition, beginning in 2020, beneficiaries enrolled in
Medicare Advantage plans were allowed to use telehealth services in their home and in urban areas.
8 For the purposes of this study, we included telehealth services that Medicare had approved for payment as of February 28,
2021.
9 Prior to the pandemic, beneficiaries could receive certain services, such as virtual check-ins, through audio-only.
10 For more information, see DOJ, “Federal Law Enforcement Action Involving Fraudulent Genetic Testing Results in Charges
Against 35 Individuals Responsible for Over $2.1 Billion in Losses in One of the Largest Health Care Fraud Schemes Ever
Charged,” September 27, 2019; see also DOJ, “National Health Care Fraud and Opioid Takedown Results in Charges Against
345 Defendants Responsible for More Than $6 Billion in Alleged Fraud Losses,” September, 30, 2020; see also DOJ, “DOJ
Announces Coordinated Law Enforcement Action To Combat Health Care Fraud Related to COVID-19,” May 26, 2021; see also
DOJ, “Nationwide Coordinated Law Enforcement Action to Combat Telemedicine, Clinical Laboratory, and Durable Medical
Equipment Fraud,” July 20, 2022.
11 The analysis includes billing by individual practitioners but not by institutions, such as hospitals.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Endnotes | 31
12 If these services were provided as billed, it raises concerns about the quality of services.
For example, providers who billed
for a high number of days or a high number of beneficiaries may not be providing proper supervision or spending an adequate
amount of time with each beneficiary.
13 This amount includes Medicare payments, beneficiary copays and deductible amounts, and any third-party payments for
services billed to Medicare-fee-for-service.
14 For the purposes of this report, we refer to the organization that billed Medicare for the telehealth service as the medical
practice.
15 These companies are also referred to as direct-to-consumer telehealth vendors. A provider may be associated with more
than one telehealth company. For more information on telehealth companies, see University of Michigan Institute for
Healthcare Policy and Innovation, Telehealth Research Incubator’s Research Snapshots, July 2021. Accessed at
https://ihpi.umich.edu/sites/default/files/2021-08/Telehealth_Research_Snapshots_Databook_2021.pdf on January 7, 2022.
16 Only the physician or practitioner may receive payment for the telehealth service, and only the facility may bill for the facility
fee. The physician or practitioner who provides the telehealth service may not bill or receive payment for the facility fee. See
42 CFR §§ 414.65(a)(1) and (b)(2).
17 See CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, p. 62. Accessed at
https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf, on December 28, 2021.
18 We focused our analysis on certain types of services that providers can bill for at different levels depending on their
complexity or duration; these services include office visits, nursing home visits, assisted living visits, and home visits.
19 To bill for an office visit that was prolonged, providers bill one or more procedure codes that indicate the extra number of
minutes that the service was prolonged. These procedure codes have specific payment amounts associated with them.
20 Five of these providers always billed for the highest level for two types of visits, such as assisted living visits and home visits.
21 A total of 18,034 providers billed both Medicare fee-for-service and Medicare Advantage for the same telehealth service for
the same beneficiary on the same date of service at least once. Although each of these providers billed this way at least once,
we did not consider them high risk unless they billed this way for more than 20 percent of their claims and encounters.
22 We analyzed hours per visit to avoid the problem of “incident to” billing. Regardless of whether the practitioner or clinical
staff are providing services “incident to” the practitioner, it is concerning that they are consistently billing for telehealth visits
that last longer than 2 hours—especially in relation to the median length of 21 minutes per visit.
23 CMS, Medicare Fraud & Abuse: Prevent, Detect, Report, January 2021.
Accessed at https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf on April 22, 2021.
24 We focused this analysis on providers who ordered medical equipment and supplies billed to Medicare fee-for-service.
Medicare Advantage plans are not required to report information about the ordering provider to Medicare.
25 85 Fed. Reg. 19230 (Apr. 6, 2020).
26 In these cases, the providers billed for the telehealth services.
For more information on the differences between telehealth
fraud and telefraud, see OIG, “Principal Deputy Inspector General Grimm on Telehealth,” February 26, 2021. Accessed at
https://oig.hhs.gov/coronavirus/letter-grimm-02262021.asp on February 10, 2022.
27 These schemes also involved genetic testing laboratories, and pharmacies. See DOJ, “National Health Care Fraud
Enforcement Action Results in Charges Involving Over $1.4 Billion in Alleged Losses,” September 17, 2021; see also DOJ,
“Nationwide Coordinated Law Enforcement Action to Combat Telemedicine, Clinical Laboratory, and Durable Medical
Equipment Fraud,” July 20, 2022.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Endnotes | 32
28 For more information on CMS’s Fraud Prevention System and Healthcare Fraud Prevention Partnership, see
https://www.cms.gov/About-CMS/Components/CPI/CPI-Investing-In-Data-and-Analytics.
29 OIG has additional evaluations and audits underway examining telehealth in Medicare to help further inform program
policies and oversight. See the HHS-OIG Work Plan, which can be found at https://oig.hhs.gov/reports-and-
publications/workplan/index.asp.
30 These reports are limited to Medicare fee-for-service claims.
Further information on the Comparative Billing Reports that
CMS sends to providers can be found at https://cbr.cbrpepper.org/home.
31 OIG, Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services, OEI-09-06-00430, August
2009.
32 There may be clinical staff without an individual identification number billing “incident to” a supervising practitioner. In
these instances, we would not expect providers to report the clinical staff’s identification number.
33 The Medicare Payment Advisory Commission has noted that there are quality of care and beneficiary safety concerns related
to the use of remote supervision when the supervising practitioner is not physically available to help if necessary. See 86 Fed.
Reg. 64996 (Nov. 19, 2021).
34 Medicare Payment Advisory Commission, Report to Congress March 2021, Chapter 14: Telehealth in Medicare after the
coronavirus public health emergency. Accessed at https://www.medpac.gov/wp-
content/uploads/2021/10/mar21_medpac_report_ch14_sec.pdf on January 4, 2022.
35 Telehealth companies may have lower costs than providers who see beneficiaries in person. See Medicare Payment Advisory
Commission, Report to Congress March 2021, Chapter 14: Telehealth in Medicare after the coronavirus public health emergency.
Accessed at https://www.medpac.gov/wp-content/uploads/2021/10/mar21_medpac_report_ch14_sec.pdf on January 4, 2022.
36 CMS, Telehealth Services, June 2021.
Accessed at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf on August 11, 2022.
37 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established
relationship, OEI-02-20-00521, October 2021; OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries
During the First Year of the COVID-19 Pandemic, OEI-02-20-00520, March 2022; OIG, 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, OEI-02-20-00522, September 2022.
38 We also supplemented this information with data from other sources, such as CMS contractor data and the Medicare
Provider Enrollment, Chain, and Ownership System.
39 The codes used in the analysis include those on the list available on the CMS website as of February 28, 2021, which can be
found at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes. These codes also
include the communication technology-based services—referred to in this report as virtual care services—that were allowed
during the first year of the pandemic. See 85 Fed. Reg. 19230 (Apr. 6, 2020) and 84472 (Dec. 28, 2020).
40 We included all virtual care services as being provided via telehealth as they can only be provided remotely.
41 We included professional services billed to Medicare fee-for-service and Medicare Advantage. We did not include telehealth
services provided directly by institutional entities, such as hospitals and nursing homes.
42 The Tukey method identifies outliers that are above the 75th percentile plus three times the interquartile range.
43 This analysis included providers who billed 10 or more visits. Further, this analysis includes only individual providers that
billed for both a facility fee and a telehealth service. In some instances, an institutional provider, such as a hospital outpatient
department, is able to bill for both the facility fee and a telehealth service for the same visit. Such providers were not included
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Endnotes | 33
in this analysis. For more detail, see CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS)
Billing. Accessed at https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf on December 28, 2021.
44 Some procedures may be billed with more than one service unit in the same visit. For the purposes of this report, we
considered one service unit to be one service. In addition, this analysis included providers who billed 50 or more services.
45 This analysis included providers who billed 50 or more services.
46 This analysis included providers with 25 or more telehealth visits.
It did not include services that take more than 100 minutes
and psychological testing and evaluation procedures. To calculate the average number of hours of services for each visit, we
used the median number of minutes for each service provided by CMS. For more information on CMS’s calculation of the
median number of minutes per service, see https://www.cms.gov/medicaremedicare-fee-service-
paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-f.
47 When determining this threshold, we considered other research on provider caseload size. See J. Altschuler, D. Margolius, T.
Bodenheimer, and K. Grumbach, “Estimating a reasonable patient panel size for primary care physicians with team-based task
delegation.” Annals of Family Medicine, Vol. 10, No. 5, 2012, p. 396.
48 This analysis included providers with 50 or more beneficiaries.
49 We focused on the six telehealth services that can be identified as being provided through audio-only.
We did not include
the other telehealth services that may be provided through audio-only because it cannot be distinguished whether they were
provided as audio-only services or as audio-video services.
50 We determined that providers worked for the same medical practice if they had the same billing National Provider Identifier
on their claims and encounters.
51 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established
relationship, OEI-02-20-00521, October 2021.
52 CMS, CMS Manual System: Nursing Facility Services (Codes 99304–99318), April 2008.
Accessed at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1489CP.pdf on March 19, 2021.
53 CGS Administrators, Fact Sheet: Subsequent Nursing Facility Care, February 2019. Accessed at
https://www.cgsmedicare.com/partb/mr/pdf/99307.pdf on March 19, 2021.
54 Ibid.
55 Noridian, Home and Domiciliary Visits, August 2019.
Accessed at
https://med.noridianmedicare.com/web/jfb/specialties/em/home-and-domiciliary-visits on March 19, 2021.
56 Ibid.
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
OEI-02-20-00720 Endnotes | 34
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