Montana Generally Complied With Requirements for Telehealth Services During the COVID-19 Pandemic, A-07-21-03250
- Issuer
- Office of Inspector General
- Document type
- Report
- Date
- 2020-12-31
Summary
An audit report, No. A-07-21-03250, issued in May 2023 by the Department of Health and Human Services Office of Inspector General on Montana Medicaid telehealth services during the COVID-19 pandemic. The audit covered 440,003 Medicaid telehealth paid claim lines totaling $43,231,910 (Federal share) with paid dates of March 1 through December 31, 2020. The report finds that 439,882 lines complied with Federal and State requirements, while 121 lines totaling $9,589 (Federal share) did not, citing missing documentation, services required to be face-to-face, and incorrect telehealth coding. It attributes the errors to the absence of claim payment system edits and recommends that Montana develop and implement such edits. The report states that Montana did not provide formal comments, and its appendices cover audit scope and methodology and Federal and State requirements.
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Full text
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
MONTANA GENERALLY
COMPLIED WITH REQUIREMENTS
FOR TELEHEALTH SERVICES
DURING THE COVID-19
PANDEMIC
Inquiries about this report may be addressed to the Office of Public Affairs at
Public.Affairs@oig.hhs.gov.
Amy J. Frontz
Deputy Inspector General
for Audit Services
May 2023
A-07-21-03250
Office of Inspector General
https://oig.hhs.gov/
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THIS REPORT IS AVAILABLE TO THE PUBLIC
at https://oig.hhs.gov
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that OIG post its publicly available reports on the OIG website.
OFFICE OF AUDIT SERVICES FINDINGS AND OPINIONS
The designation of financial or management practices as
questionable, a recommendation for the disallowance of costs
incurred or claimed, and any other conclusions and
recommendations in this report represent the findings and
opinions of OAS. Authorized officials of the HHS operating
divisions will make final determination on these matters.
Report in Brief
Date: May 2023
Report No. A-07-21-03250
Why OIG Did This Audit Montana Generally Complied With Requirements
Medicaid telehealth refers to the
services performed via a for Telehealth Services During the COVID-19
telecommunication system. A Pandemic
Medicaid patient at an originating
site uses audio and video equipment
to communicate with a health
What OIG Found
Montana and Medicaid providers generally complied with Federal and State
professional at a distant site.
requirements when claiming Medicaid reimbursement for telehealth services
during the COVID-19 pandemic. Over 99.9 percent of the lines we reviewed
Because of the speed with which the
complied with Federal and State requirements. However, some Medicaid
use of telehealth has expanded
providers claimed services that did not comply with requirements for
during the COVID-19 pandemic,
telehealth services. Specifically, we identified 121 lines totaling $9,589
opportunities exist for inefficiencies
(Federal share), each of which had 1 of the following types of errors:
and potential abuse in the telehealth
documentation did not support that services were performed; services were
system. Rapid expansion of
required to be face-to-face but were instead performed and billed as
telehealth may pose challenges for
telehealth; or services were performed but providers incorrectly added a
providers and State agencies,
modifier or place of service code to indicate that the services were performed
including State oversight of these
via telehealth.
services.
These errors occurred because Montana’s claim payment system did not have
Our objective was to determine
edits to ensure that only specific procedure codes eligible to be performed via
whether Montana and Medicaid
telehealth were billed as telehealth.
providers complied with Federal and
State requirements when claiming
Medicaid reimbursement for What OIG Recommends and Montana Comments
telehealth services during the We recommend that Montana develop and implement edits in its claim
COVID-19 pandemic. payment system so that it pays only telehealth claims whose procedure codes
denote the associated services as eligible to be performed via telehealth.
How OIG Did This Audit
Montana did not provide formal comments on our draft report. However, a
Our audit covered 440,003 Medicaid
Montana official told us that Montana did not have any disagreements with
telehealth paid claim lines (lines),
our findings. We will continue to track the recommendation to ensure that
totaling $43.2 million (Federal share),
Montana takes steps to implement it.
that Montana claimed with paid
dates of March 1 through
December 31, 2020. We asked
Montana to review the procedure
codes paid as telehealth and identify
which were allowable for billing as
telehealth. We reviewed the
supporting documentation to
determine whether the providers had
documentation to support that the
services were rendered.
The full report can be found at https://oig.hhs.gov/oas/reports/region7/72103250.asp.
TABLE OF CONTENTS
INTRODUCTION .............................................................................................................................. 1
Why We Did This Audit ...................................................................................................... 1
Objective ............................................................................................................................ 1
Background ........................................................................................................................ 1
Administration of the Medicaid Program and Telehealth ..................................... 1
Telehealth Services in Montana During the COVID-19 Pandemic ......................... 2
Telehealth Reimbursement in Montana................................................................ 2
How We Conducted This Audit .......................................................................................... 3
FINDINGS ........................................................................................................................................ 3
The State Agency and Providers Claimed Telehealth Services That Did Not
Comply With Requirements ............................................................................................ 4
Services for Which Documentation Did Not Support That Services
Were Performed.................................................................................................. 4
Services Performed and Billed as Telehealth but Required To Be
Performed Face-to-Face ...................................................................................... 5
Services Performed but Incorrectly Billed as Telehealth ....................................... 5
Some Telehealth Services Did Not Comply With Requirements Primarily Because
the State Agency Did Not Have Edits in Place To Ensure Correct Telehealth Billing ...... 5
Effect on Payments of Telehealth Claims That Did Not Comply With Applicable
Requirements .................................................................................................................. 6
RECOMMENDATION ...................................................................................................................... 6
STATE AGENCY COMMENTS .......................................................................................................... 6
APPENDICES
A: Audit Scope and Methodology ...................................................................................... 7
B: Federal and State Requirements ................................................................................... 9
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250)
INTRODUCTION
WHY WE DID THIS AUDIT
Medicaid telehealth refers to the services performed via a telecommunication system. A
Medicaid patient at an originating site uses audio and video equipment to communicate with a
health professional at a distant site.1 Medicaid views telehealth services as a way to provide
medical services between places of lesser and greater medical capability or expertise, or both,
for the purpose of evaluation and treatment.
Under the President’s national emergency declaration and the Secretary of Health and Human
Services’s public health emergency declaration, the Centers for Medicare & Medicaid Services
(CMS) has temporarily waived certain requirements and encouraged States to exercise broad
flexibilities for the provision of telehealth services to minimize the impact of COVID-19 on
health care facilities, decrease community spread of COVID-19, and increase access to medical
care. By expanding access to telehealth, people who are self-isolating are allowed to continue
receiving medical services from their homes, which frees space in hospitals and other health
care facilities for COVID-19 patients who require in-person care. Expanding access to telehealth
also allows people to continue to receive regular services, such as wellness checks, therapy
appointments, and more, while physical distancing orders are in place.
Because of the speed with which the use of telehealth has expanded during the COVID-19
pandemic, opportunities exist for inefficiencies and potential abuse in the telehealth system.
Rapid expansion of telehealth may pose challenges for providers and State agencies, including
State oversight of these services.
OBJECTIVE
Our objective was to determine whether the Montana Department of Public Health and Human
Services (State agency) and Medicaid providers complied with Federal and State requirements
when claiming Medicaid reimbursement for telehealth services during the COVID-19 pandemic.
BACKGROUND
Administration of the Medicaid Program and Telehealth
The Medicaid program provides medical assistance to low-income individuals and individuals
with disabilities. The Federal and State Governments jointly fund and administer the Medicaid
program. At the Federal level, CMS administers the program. Each State administers its
Medicaid program in accordance with a CMS-approved State plan. Although the State has
considerable flexibility in designing and operating its Medicaid program, it must comply with
1
See “Telehealth Services in Montana During the COVID-19 Pandemic” later in this report for definitions of
“originating site” and “distant site.”
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 1
applicable Federal requirements. In Montana, the State agency administers the Medicaid
program.
For purposes of Medicaid, telehealth seeks to improve a patient’s health by permitting two-
way, real-time interactive communication between a patient at an originating site and a
provider at a distant site. States may claim Federal financial participation (FFP or Federal share)
for amounts expended as medical assistance under the State plan (Social Security Act
§ 1903(a)). Claims for Federal Medicaid reimbursement must be supported by adequate
documentation to ensure that all applicable Federal requirements have been met (CMS State
Medicaid Manual § 2497.1). Additionally, costs must be adequately documented to be
allowable under Federal awards (45 CFR § 75.403(g)).
Telehealth Services in Montana During the COVID-19 Pandemic
The Directive signed by the Governor of Montana on March 20, 2020, expands telehealth
services in response to the COVID-19 pandemic. The relaxed telehealth requirements were
outlined in a Montana Disaster Relief State Plan Amendment. The expanded guidance allows
any enrolled provider operating within its scope of practice, and with the appropriate license or
certification, to serve as a distant site provider. Telehealth services are delivered to a patient
who is located at an originating site. Any site that allows the patient to use a communication or
technology system may be an originating site, including a patient’s home.
Telehealth Reimbursement in Montana
To be eligible for reimbursement, the telehealth service must be medically necessary and
clinically appropriate for delivery via telehealth. Reimbursement for telehealth services is made
at the same rate as that paid for Medicaid health services delivered face-to-face.
The Medicaid statute does not recognize telehealth as a distinct service, and States have
significant flexibility to establish telehealth payment methodologies and requirements. In
Montana, any Montana health care program provider can bill for telehealth, if that mode of
service is appropriate within their license and scope of practice. Additionally, services delivered
via telehealth are reimbursable so long as they: (1) are medically necessary and clinically
appropriate for delivery via telehealth, (2) comport with the guidelines set forth in the
applicable Montana Medicaid provider manual, and (3) are not a service specifically required to
be face-to-face as defined in the applicable Montana Medicaid provider manual.
Additionally, if a provider cannot furnish medical records to prove that a service billed to
Medicaid was performed and meets all requirements for reimbursement, the service will be
deemed not to have been performed, and not reimbursable, because of the lack of
documentation, and the State agency will recover all reimbursement paid to that provider. This
recovery is permissible regardless of whether the documentation was destroyed or lost due to
an event such as (but not limited to) misplaced records, a data processing failure, fire,
earthquake, flood, or other natural disaster. The provider must have a backup system in place
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 2
to allow recovery of documentation destroyed or lost due to such events or any other cause
(Montana Medicaid Disaster Relief State Plan Amendment 20-0024, effective March 1, 2020,
and Administrative Rules of Montana (ARM) 37.85.414(1)(g)).
Distant site providers submit claims for telehealth services using the appropriate Healthcare
Common Procedure Coding System (HCPCS) code for the professional service along with the
telehealth modifier “GT” or place of service code “02.”2 The originating site provider is eligible
to receive only a facility fee for telehealth services, billed using HCPCS code Q3014.
HOW WE CONDUCTED THIS AUDIT
Our audit covered 440,003 Medicaid telehealth paid claim lines (lines), totaling $43,231,910
(Federal share), that the State agency claimed with paid dates of March 1 through
December 31, 2020 (audit period). We compiled and gave to the State agency a list of all
HCPCS codes paid as telehealth. We asked the State agency to review those HCPCS codes and
identify which were allowable for billing as telehealth. We used the HCPCS codes that the State
agency confirmed were allowable to identify the individual lines to review. We reviewed the
supporting documentation to determine whether the providers had documentation to support
that the services were performed. We did not review the payments made for services billed
using the Q3014 HCPCS code, or their associated services, because of their low dollar amount.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Appendix A contains the details of our audit scope and methodology and Appendix B contains
the Federal requirements.
FINDINGS
The State agency and Medicaid providers generally complied with Federal and State
requirements when claiming Medicaid reimbursement for telehealth services during the
COVID-19 pandemic. However, some Medicaid providers claimed services that did not comply
with requirements for telehealth services. From the list of HCPCS codes that the State agency
verified as acceptable services to be performed via telehealth, we identified 121 lines that did
not comply with Federal and State requirements. Thus, of the 440,003 lines in our audit scope,
439,882 lines complied with Federal and State requirements (over 99.9 percent), but the
remaining 121 lines totaling $9,589 (Federal share) did not. See the table on the following
page.
2
HCPCS codes are used throughout the health care industry to standardize coding for medical procedures,
services, products, and supplies.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 3
Table: Summary of Lines Not in Compliance
Number of
Type of Noncompliance Noncompliant Lines
Providers could not provide documentation to support that the
service was performed. 8
Service was required to be face-to-face but was performed and billed
as telehealth. 26
Providers incorrectly coded service as telehealth; however, service
87
was performed.
Total 121
These errors occurred because the State agency’s claim payment system did not have edits to
ensure that only specific HCPCS codes eligible to be performed via telehealth were billed as
telehealth. According to the State agency, the edits were not in place because of the age of the
State agency’s claim payment system and the speed with which telehealth-related changes
were rolled out in the COVID-19 pandemic. Additionally, some providers did not always
maintain documentation to support services performed. As a result, we identified 121 lines
totaling $9,589 (Federal share) that did not comply with applicable requirements.
THE STATE AGENCY AND PROVIDERS CLAIMED TELEHEALTH SERVICES THAT DID NOT
COMPLY WITH REQUIREMENTS
Services for Which Documentation Did Not Support That Services Were Performed
Costs must be adequately documented to be allowable under Federal awards (45 CFR
§ 75.403(g)). Additionally, claims for Federal Medicaid reimbursement must be supported by
adequate documentation to ensure that all applicable Federal requirements have been met
(CMS State Medicaid Manual § 2497.1). Furthermore, State requirements specify that if a
provider cannot furnish medical records to prove that a service billed to Medicaid was
performed and that it meets all requirements for reimbursement, the service will be deemed
not to have been performed, and not reimbursable, because of the lack of documentation
(ARM 37.85.414(1)(g)).
For eight lines, providers billed for services for which documentation did not support that the
services were performed. Specifically, for six lines, the supporting documentation did not
support that the services were performed. For example, one provider billed for an influenza
vaccine; the associated documentation supported other services being provided but did not
support the administration of a vaccine. For two other lines, the provider could not furnish any
documentation to support that the services were performed.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 4
Services Performed and Billed as Telehealth but Required To Be Performed Face-to-Face
State requirements for telehealth services state that covered services delivered via telehealth
are reimbursable so long as such services are medically necessary and clinically appropriate for
delivery via telehealth, comport with the guidelines set forth in the applicable Montana
Medicaid provider manual, and are not a service specifically required to be face-to-face as
defined in the applicable Montana Medicaid provider manual (Montana Medicaid Disaster
Relief State Plan Amendment 20-0024, effective March 1, 2020).
For 26 lines, the services were required to be face-to-face but were instead performed via
telehealth. For example, for 25 of these lines, the services billed were for mental health partial
hospitalization. According to the associated HCPCS codes that the State agency gave us, this
type of service must be performed on a face-to-face basis.
Services Performed but Incorrectly Billed as Telehealth
Some of the lines we reviewed did not support that the services were performed via telehealth.
Specifically, for 87 lines, we found documentation to support that the services were performed;
however, in each case the providers incorrectly added a modifier or place of service code to
indicate that the service was performed via telehealth. For example, for two lines, the
documentation noted telehealth as the place of service, but the services performed were for
alcohol or other drug testing, for which telehealth is not an appropriate place of service.
SOME TELEHEALTH SERVICES DID NOT COMPLY WITH REQUIREMENTS PRIMARILY BECAUSE
THE STATE AGENCY DID NOT HAVE EDITS IN PLACE TO ENSURE CORRECT TELEHEALTH BILLING
The COVID-19 pandemic and the rapid expansion of telehealth may have posed challenges for
the State agency and its providers. Although the State agency generally complied with the
expanded telehealth billing requirements, it did not have edits in place to ensure that only
services whose specific HCPCS codes denoted them as eligible to be performed via telehealth
were billed as telehealth. According to the State agency, the edits were not in place because of
the age of the State agency’s claim payment system and the speed with which telehealth-
related changes were rolled out in the COVID-19 pandemic. This resulted in payments for
services billed as telehealth that could not be performed in a telehealth setting. Although the
lack of claims edits did not result in significant overpayments, the potential exists that future
overpayments could occur if this vulnerability is not remedied. Additionally, other telehealth
billing errors occurred because providers did not always maintain documentation to support
that the services were performed.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 5
EFFECT ON PAYMENTS OF TELEHEALTH CLAIMS THAT DID NOT COMPLY WITH APPLICABLE
REQUIREMENTS
We identified 121 lines totaling $9,589 (Federal share) that did not comply with applicable
requirements.3 Specifically, for the lines of service that could not be supported, the State
agency overpaid providers $129 (Federal share). For the lines of service that were billed as
telehealth but were required to be face-to-face, some of the $4,250 (Federal share) in
associated payments may have been allowable if billed under another HCPCS code, which could
affect the amount paid. Finally, for the lines of service performed but incorrectly billed as
telehealth, incorrect coding could affect the accurate reporting of $5,210 (Federal share) in
associated payments for telehealth services.
RECOMMENDATION
We recommend that the Montana Department of Public Health and Human Services develop
and implement edits in its claim payment system so that the State agency pays only telehealth
claims whose HCPCS codes denote the associated services as eligible to be performed via
telehealth.
STATE AGENCY COMMENTS
The State agency did not provide formal comments on our draft report. However, a State
agency official told us that the State agency did not have any disagreements with our findings.
We will continue to track the recommendation to ensure that the State agency takes steps to
implement it.
3
Given that audited funds exceeded $43 million and in light of the de minimis amounts in error, we did not make
formal recommendations to the State agency to reprocess the claims (and refund the Federal share) that did not
comply with requirements. However, we shared the detailed claim information with the State agency to allow it to
take appropriate corrective actions.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 6
APPENDIX A: AUDIT SCOPE AND METHODOLOGY
SCOPE
Our audit covered 440,003 Medicaid telehealth paid claim lines (lines), totaling $43,231,910
(Federal share), that the State agency claimed with paid dates of March 1 through
December 31, 2020 (audit period).
We worked with the State agency to develop a list of HCPCS codes paid as telehealth, to verify
the allowability of those HCPCS codes, and we reviewed selected individual lines, their
associated payments, and relevant supporting documentation.
We did not review the payments made for services billed using the Q3014 HCPCS code
(footnote 2), or their associated services, because of their low dollar amount. We assessed
internal controls and compliance with laws and regulations necessary to satisfy the audit
objective. In particular, we assessed internal controls related to provider submissions of claims
for telehealth services using the telehealth modifier or place of service code. However,
because our review was limited to this aspect of internal control, it may not have disclosed all
internal control deficiencies that may have existed at the time of this audit. Any internal
control deficiencies we found are discussed in this report.
We performed our audit work from May 2021 to March 2023.
METHODOLOGY
To accomplish our objective, we:
• reviewed applicable Federal and State laws, regulations, and guidance;
• interviewed State agency officials to gain an understanding of the provision of and
payment for telehealth services in Montana;
• compared Medicaid fee-for-service payment data furnished by the State agency for our
audit period to CMS Transformed Medicaid Statistical Information System data obtained
by our Division of Data Analytics to ensure the reliability of the claims data that the
State agency gave us;4
• compiled a list of all HCPCS codes paid as telehealth, gave it to the State agency, and
asked the State agency to identify which of those HCPCS codes were allowable for billing
as telehealth;
4
These CMS data aggregate Medicaid claims data furnished quarterly by State agencies to CMS.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 7
• using the HCPCS codes that the State agency confirmed as allowable, identified
payments for services that were not allowable to be performed via telehealth and asked
the State agency to give us supporting documentation for these payments;
• performed additional testing on the payments that we had identified, by reviewing the
supporting documentation to determine whether the providers had documentation to
support that the services were performed via telehealth; and
• discussed our findings with State agency officials on November 30, 2022.
We conducted this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions
based on our audit objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 8
APPENDIX B: FEDERAL AND STATE REQUIREMENTS
FEDERAL REQUIREMENTS
Section 1903(a) of the Act states:
From the sums appropriated therefor, the Secretary (except as otherwise
provided in this section) shall pay to each State which has a plan approved under
this title, for each quarter, beginning with the quarter commencing January 1,
1966—
(1) an amount equal to the Federal medical assistance percentage (as defined in
section 1905(b), subject to subsections (g) and (j) of this section and subsection
1923(f)) of the total amount expended during such quarter as medical assistance
under the State plan. . . .
Federal regulations state: “Definitions of services for FFP purposes. Except as limited in part
441, FFP is available in expenditures under the State plan for medical or remedial care and
services as defined in this subpart” (42 CFR § 440.2(b)).
Federal regulations also state: “Except where otherwise authorized by statute, costs must meet
the following general criteria in order to be allowable under Federal awards . . . . (g) Be
adequately documented” (45 CFR § 75.403).
CMS’s State Medicaid Manual states: “Federal financial participation (FFP) is available only for
allowable actual expenditures made on behalf of eligible recipients for covered services
rendered by certified providers. Expenditures are allowable only to the extent that, when a
claim is filed, you have adequate supporting documentation in readily reviewable form to
assure that all applicable Federal requirements have been met” (§ 2497.1).
STATE REQUIREMENTS
The Montana Medicaid Disaster Relief State Plan Amendment 20-0024, effective March 1,
2020, states (on pages 5 – 6):
Covered Telemedicine/Telehealth Services
All Montana Medicaid covered services delivered via telemedicine/telehealth are
reimbursable so long as a) such services are medically necessary and clinically
appropriate for delivery via telemedicine/telehealth, b) comport with the
guidelines set forth in the applicable Montana Medicaid provider manual, and
c) are not a service specifically required to be face-to-face as defined in the
applicable Montana Medicaid provider manual.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 9
Allowable Telemedicine/Telehealth Methods and Technologies
There are no specific requirements for technologies used to deliver services via
telemedicine/telehealth and can be provided using: secure portal messaging,
secure instant messaging, telephone conversations, and audio-visual
conversations.
Requirements for telemedicine/telehealth encounters
• To the extent possible, providers must ensure members have the same rights
to confidentiality and security as provided during traditional office visits.
• Providers must follow consent and patient information protocol consistent
with those followed during in person visits.
• Telemedicine/telehealth does not alter the scope of practice of any health
care provider; or authorize the delivery of health care services in a setting or
manner not otherwise authorized by law.
• Record keeping must comply with [ARM] 37.85.414.
ARM 37.85.414(1)(g) states:
If a provider cannot provide medical records to prove that a service billed to
Medicaid was provided and meets all requirements for reimbursement, the
service will be deemed not to be provided and reimbursable due to the lack of
documentation, and the department will recover all reimbursement paid to the
provider. This recovery is permissible regardless of whether the documentation
was destroyed or lost due to an event such as, but not limited to, misplaced
records, a data processing failure, fire, earthquake, flood, or other natural
disaster. The provider must have a backup system in place to allow recovery of
documentation destroyed or lost due to such events or any other cause.
Montana Telehealth Services During the COVID-19 Pandemic (A-07-21-03250) 10
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