Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic

Issuer: Department of Justice
Document type: Report
Date: 2022-12-01

Summary

A December 2022 report by the Pandemic Response Accountability Committee's Health Care Subgroup on telehealth use and program integrity risks in selected health care programs across six federal agencies during the first year of the pandemic. The programs are Medicare, TRICARE, the Federal Employees Health Benefits Program, the Veterans Health Administration, the Office of Workers' Compensation Programs and DOJ prisoner health care services. The report states that approximately 37 million individuals used telehealth in these programs during that year, compared with 3 million in the prior year. The Offices of Inspectors General identify risks such as high-volume billing and duplicate claims, and a lack of data to assess quality of care. The report contains a data report, agency details for HHS, DoD, OPM, VA, DOL and DOJ, and methodology appendices.

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Full text

Insights on Telehealth
Use and Program Integrity
Risks Across Selected
Health Care Programs
During the Pandemic
December 2022

PANDEMIC RESPONSE
ACCOUNTABILITY COMMITTEE

Insights on Telehealth Use and
Program Integrity Risks

Message from the Pandemic
Response Accountability Committee
The pandemic changed many aspects of our lives, including how we visit the doctor and other
health care providers. Reliance on telehealth services—that is, health care services that are
provided remotely using technology between a provider and a patient—skyrocketed during the first
year of the pandemic, especially among federal health care programs.
Pandemic Response Accountability Committee’s (PRAC’s) Health Care Subgroup developed this
report to share insights about the use of telehealth in selected programs across six federal agencies
during the first year of the COVID-19 pandemic.
Together, these programs provided telehealth services
The selected programs in six agencies include:
to approximately 37 million individuals during that
year, a dramatic increase from the 3 million individuals
1. Medicare | Department of Health and
Human Services
who accessed telehealth during the prior year. The
PRAC identified access to telehealth as among the top
2. TRICARE | Department of Defense
challenges facing federal agencies in their COVID-19
3. Federal Employees Health Benefits
response efforts in both 2020 and 2021.1
Program | Office of Personnel Management
We undertook this study to examine the expansion of
telehealth across federal programs during the pandemic
and, along with this expansion, the emerging risks.

4. Veterans Health Administration |
Department of Veterans Affairs
5. Office of Workers’ Compensation
Programs | Department of Labor

6. Federal Bureau of Prisons and U.S.
This report summarizes potential program integrity risks
Marshals Service (“DOJ prisoner health
identified by the six participating Offices of Inspectors
care services”) I Department of Justice
General (OIGs). We wrote this report to inform
stakeholders—including Congress; federal and state
agencies; and health care organizations—how expanded
use of telehealth during the COVID-19 pandemic helped individuals access health care during a
crisis, and to raise awareness about the critical importance of safeguarding expanded telehealth
services against fraud, waste, and abuse.

Among the key findings across federal health care programs, OIGs identified:
• Dramatic increases in the use of telehealth during the first year of the pandemic.
• A variety of telehealth services that were available to patients.
• Similar program integrity risks that might indicate fraud, waste, or abuse, such as high-volume
billing, duplicate claims, and inappropriate charges for the most expensive level of telehealth
services.
• A lack of data to assess quality of care and conduct comprehensive oversight of telehealth
services.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

While the selected programs have safeguards in place to monitor telehealth services, additional
controls could strengthen program integrity and ensure accurate payments. For example, programs
could conduct additional monitoring of telehealth services; enhance efforts to educate providers
and individuals about telehealth services; and develop additional billing controls to prevent
inappropriate payments.
Taken together, the insights in this report demonstrate the importance of ensuring that the benefits
of telehealth are realized across federal health care programs in an effective and efficient manner,
while minimizing programmatic and financial risks. Therefore, the PRAC encourages agencies,
policymakers, and stakeholders to rely on these insights to inform future decisions on telehealth
and to protect against fraud, waste, and abuse.

About the PRAC
The CARES Act created the PRAC to coordinate oversight of the federal government’s pandemic
response and historic level of spending. The PRAC’s Health Care Subgroup consists of OIGs that
oversee the federal agencies that provide or reimburse for health care services. By working together
and sharing data, the Health Care Subgroup provides coordinated oversight across agencies and
programs.

Michael E. Horowitz
Chair, PRAC
Inspector General, U.S. Department of Justice

Christi A. Grimm
Chair, PRAC Health Care Subgroup
Inspector General, U.S. Department of Health
and Human Services

Sean W. O’Donnell
Acting Inspector General, U.S. Department
of Defense

Krista A. Boyd
Inspector General, U.S. Office of Personnel
Management

Michael J. Missal
Inspector General, U.S. Department
of Veterans Affairs

Larry D. Turner
Inspector General, U.S. Department of Labor

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

Contents
Message from the Pandemic Response Accountability Committee

Data Report

Insights on Telehealth Use and Program Integrity Risks
Across Selected Health Care Programs During the Pandemic
Agency Details

1
27

U.S. Department of Health and Human Services (HHS)

U.S. Department of Defense (DoD)

U.S. Office of Personnel Management (OPM)

U.S. Department of Veterans Affairs (VA)

U.S. Department of Labor (DOL)

U.S. Department of Justice (DOJ)

Appendix A: HHS

Appendix B: DoD

Appendix C: OPM

Appendix D: VA

Appendix E: DOL

102

Appendix F: DOJ

104

Pandemic Response Accountability Committee

iii

Data Report

Insights on Telehealth Use and Program
Integrity Risks Across Selected Health Care
Programs During the Pandemic

The COVID-19 pandemic created unprecedented challenges for access to health care in the United
States. In response, many federal health care programs took actions to expand access to health
care services provided through telehealth. Telehealth services—health care services that are
provided remotely using technology between a provider and a patient—allow providers to evaluate
and treat patients at home or elsewhere without the added risk of transmitting COVID-19. Providers
can also use telehealth to provide critical services when in-person care is not readily accessible,
which may be particularly valuable for vulnerable populations.
Throughout the pandemic, the use of telehealth has been
crucial in ensuring continued access to health care in
multiple federal health care programs. As a result, the PRAC
Health Care Subgroup has identified the expanded use
of telehealth services as critical to the federal COVID-19
response efforts and to the efficiency and economy of those
efforts. In addition, while the expansion of telehealth has
been essential to maintaining individuals’ access to care,
there have been concerns about the potential for fraud,
waste, and abuse associated with expanded telehealth
services.
This report provides policymakers and stakeholders—
such as Congress; federal and state agencies; and health
care organizations—with information about the nature of
telehealth and its use across selected health care programs
in six federal agencies during the first year of the pandemic.
It also provides insights into the program integrity risks
associated with telehealth and safeguards that could
strengthen oversight in these programs. These insights
can help inform decisions on which telehealth changes
should remain after the pandemic and how programs can
incorporate appropriate safeguards to protect against fraud,
waste, and abuse.

Pandemic Response Accountability Committee

During the first year of
the pandemic, approximately
37 million

individuals used telehealth services
across the selected programs in six
federal agencies,

13 times

the number of individuals who used
telehealth the prior year.

Prior to the
pandemic
During the first

year of the pandemic

Source: Analysis of data from selected federal
health care programs, 2022.

Insights on Telehealth Use and
Program Integrity Risks

HOW WE CONDUCTED THIS STUDY
The PRAC Health Care Subgroup comprises six Offices of Inspectors General (OIGs) responsible for
the oversight of agencies that provide or are involved with the provision of health care services.
These agencies are the Department of Health and Human Services (HHS), the Department of
Defense (DoD), the Office of Personnel Management (OPM), the Department of Veterans Affairs
(VA), the Department of Labor (DOL), and the Department of Justice (DOJ). For this review, the
six OIGs selected programs or components within their agencies for which they could obtain data
on the use of telehealth during the first year of the pandemic. Throughout this report, we use the
term “program” to refer to these programs and components. We also use the term “individual” to
represent the beneficiaries or persons served by each of these programs.
The nature of the health care programs selected for review vary. While most of the programs
exclusively pay for health care delivered by providers in the community, other programs deliver care
directly to individuals and, under certain circumstances, pay for care delivered by providers in the
community, among other arrangements.2 The programs also vary in size and population. See Exhibit
1 for more information about the federal health care programs selected for this report, such as the
populations that each serves and the role of each in providing telehealth services.
Each OIG collected data on the nature and use of telehealth in the year prior to the pandemic
(March 2019 through February 2020) and during the first year of the pandemic (March 2020
through February 2021) and identified program integrity risks and safeguards associated with
telehealth in the selected health care program. The data that the six OIGs collected focused on four
questions.
1. To what extent did the selected programs in six federal agencies make telehealth services
available to individuals during the pandemic?
2. To what extent did individuals served by the selected programs use telehealth services
during the first year of the pandemic?
3. What types of program integrity risks are associated with the use of telehealth services?
4. What types of data and safeguards could strengthen oversight?
The General Methodology section and the more detailed methodologies in the appendices contain
additional information on how each OIG conducted its analysis.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

Exhibit 1: Federal health care programs selected for this report and the populations that they serve
Federal Health
Care Program

Population Served

Role of the program in
providing telehealth services

HHS

66 million adults age 65 years and older, as
well as those with end-stage renal disease
and people with a qualifying disability.

Medicare pays for claims for telehealth
services and contracts with Medicare
Advantage plans to provide coverage.

DoD

3.5 million military personnel and their
families enrolled in TRICARE Prime and
TRICARE Select.

TRICARE reimburses telehealth providers
through a fee-for-service arrangement based
on an allowable charge.

OPM

8 million federal employees, retirees, and
other eligible individuals.

The Federal Employees Health Benefits
Program contracts with approximately 80
insurance carriers, otherwise known as
insurers, that process and pay for claims for
telehealth services.

5.6 million enrolled veterans who actively use
VA services.3

The Veterans Health Administration provides
direct patient care, including telehealth. It
also reimburses third-party administrators
that process claims and pay non-VA providers
under the Veterans Community Care Program.

DOL

145,000 workers who filed for workers’
compensation and received medical benefits,
including federal employees who experienced
work-related injury or disease; current or
former Department of Energy workers and
contractors; and former coal miners and their
surviving dependents.

Office of Workers’ Compensation Programs
processes and pays claims for telehealth
services.

DOJ

179,000 federal prisoners, including those
housed in federal prisons (institutions)
operated by the Federal Bureau of Prisons
and those housed in detention facilities in
the custody of the United States Marshals
Service. DOJ’s United States Marshals
Service and the Federal Bureau of Prisons
are separate DOJ components with distinct
prisoner populations and health care
services. Throughout this report, we refer to
both components’ services collectively as
“DOJ prisoner health care services.”

122 institutions operated by the Federal
Bureau of Prisons provide direct care and pay
for external care provided in the community.
The United States Marshals Service maintains
agreements with over 800 state and local
detention facilities and other types of facilities
to house prisoners in its custody and relies
on these facilities to ensure prisoners receive
medical care. It also reimburses its National
Managed Care Contract contractor, which
processes and pays claims for external care
provided to its prisoners.

Medicare

TRICARE

Federal
Employees
Health
Benefits
Program

Veterans
Health
Administration
(VHA)

Office of
Workers’
Compensation
Programs

DOJ prisoner
health care
services

Source: Analysis of information from selected programs in six federal agencies, 2022.
Notes: Although DoD delivers health care in its military treatment facilities, only telehealth provided by private sector providers was
included in this review. DoD also has a program called TRICARE for Life—a type of Medicare wraparound coverage for beneficiaries
who have Medicare Parts A and B—that was not included in this review.
A fourth Workers’ Compensation program, the Longshore program, is not included in this review.
The Federal Bureau of Prisons is responsible for confining federal prisoners in controlled environments that are safe and secure, and
it must also ensure prisoners are housed in humane facilities and receive adequate health care. The United States Marshals Service
is responsible for providing safe, secure, and humane custody; housing; medical care; and transportation to prisoners awaiting trial
or sentencing decisions.
Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

TELEHEALTH POLICY
INSIGHT: The selected programs in six federal agencies took various
steps to make telehealth available during the pandemic
The selected programs took a variety of actions to help ensure telehealth was available to the
individuals they serve during the pandemic. (See Exhibit 2.)
Exhibit 2: Key Actions Taken to Ensure Availability of Telehealth During the First Year of
the Pandemic
HHS Medicare. In March 2020, Congress, HHS, and the Centers for Medicare & Medicaid Services (CMS)
temporarily expanded access to telehealth in Medicare allowing beneficiaries to use telehealth for a
wide range of services in different locations, including in urban areas and from the beneficiary’s home.
Prior to the pandemic, generally only beneficiaries in rural areas were allowed to use telehealth and they
were generally not allowed to use telehealth from home. In addition, beneficiaries were limited to using
telehealth for relatively few services.
DoD TRICARE. The Defense Health Agency temporarily expanded access to telehealth services and
created flexibility for beneficiaries to use telehealth. For example, it temporarily lifted a requirement that
patients use full audio and video during telehealth appointments, allowing patients to use audio-only.
OPM Federal Employees Health Benefits Program. In response to the pandemic, OPM issued guidance—
i.e., Carrier Letters—to the health insurance carriers that provide health benefits, urging the insurers to
review their preparedness and take necessary steps to provide services without interruption. OPM also
encouraged insurers to consider solutions that waive cost-sharing for telehealth visits associated with the
treatment of COVID-19.
VA Veterans Health Administration. Beginning in March and April 2020, the Veterans Health
Administration took actions to expand its existing telehealth program. For example, modified guidance was
issued allowing certain flexibilities related to credentialing and privileging of providers in anticipation of
staffing shortages. The Veterans Health Administration also authorized providers to utilize audio or video
communication technology for telehealth services. Further, it introduced the “digital divide consult,” where
patients are loaned a video-capable device if they lacked such resources.
DOL Office of Workers’ Compensation Programs. At the start of the pandemic, the Office of Workers’
Compensation Programs instituted new policies that expanded access to telehealth for injured workers
in its three programs by allowing routine medical care to be provided through telehealth by certain types
of medical care practitioners. Prior to the pandemic, only one of its programs—the Federal Employees
Compensation Act program—allowed telehealth.
DOJ prisoner health care services. The DOJ did not have policies specific to telehealth for prisoners in its
custody. A change the DOJ made during the pandemic was that the Federal Bureau of Prisons temporarily
waived some timeliness requirements for certain telehealth providers to complete credential verification
and privileges and helped streamline the process for approving telehealth providers.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

All of the programs issued new policies or guidance to increase access to telehealth, expanding
coverage of telehealth services and introducing new flexibilities to enable individuals to receive
care via telehealth. In addition, Congress also took legislative action to expand access to telehealth
services for beneficiaries in two programs—Medicare and the Veterans Health Administration.

INSIGHT: The selected programs in six federal agencies provided
relatively similar coverage of telehealth services during the pandemic
The selected programs provided relatively similar coverage of telehealth services during the first
year of the pandemic. The programs covered a range of telehealth services and offered flexibilities
related to where and how individuals received telehealth services. There was variation, however, in
how programs handled patient cost-sharing and provider payment amounts.

All selected programs allowed telehealth to be used for a variety of services
These services generally included visits with primary care and specialists; behavioral health care;
and physical, occupational, and speech therapy.4 Some programs also covered virtual care services,
such as telephone calls with a provider or interactions via an online patient portal, and remote
monitoring, such as weight and blood pressure checks. Programs also covered other services.
For example, Medicare covered ophthalmology services delivered using telehealth. Prior to the
pandemic, Medicare, Workers’ Compensation, and the Federal Employees Health Benefits Program
covered fewer telehealth services.5
In addition, the programs had different ways of determining which services could be provided via
telehealth. Two programs—-Medicare and Workers’ Compensation—issued a specific list of services
that could be provided via telehealth. The other programs—-the Veterans Health Administration,
TRICARE, DOJ prisoner health care services, and the Federal Employees Health Benefits Program—
allowed the provider, facility, or health insurers to determine which specific services could be
provided via telehealth.

All selected programs allowed audio-only telehealth but to varying extents
All of the programs allowed the individuals they serve to access at least some telehealth services
using audio-only during the pandemic.6 Three of the programs—TRICARE, Medicare, and Workers’
Compensation—limited audio-only telehealth to certain services, while the DOJ prisoner health care
services and Veterans Health Administration did not limit audio-only telehealth to certain services.
The Federal Employees Health Benefits Program coverage varied by insurer, with most insurers
allowing audio-only telehealth services.

Programs allowed individuals to access telehealth from their homes
None of the programs required patients to travel to health care settings to receive telehealth
services during the pandemic. All programs allowed individuals to receive telehealth in their homes
(or from prisons, when available) during the pandemic.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

Prior to the pandemic, Medicare generally required beneficiaries to travel to a health care setting,
such as a doctor’s office or hospital, to use telehealth.7 Medicare also generally limited telehealth
services to beneficiaries in rural areas prior to the pandemic. None of the other programs had
similar limitations prior to the pandemic.

All selected programs had no cost-sharing for patients or allowed cost-sharing to
be waived
In several programs, individuals had no cost-sharing, such as a copayment or coinsurance, for most
or all of their telehealth services during the first year of the pandemic. These programs included
TRICARE, the Veterans Health Administration, Workers’ Compensation, and DOJ prisoner health
care services.8 Prior to the pandemic, TRICARE and the Veterans Health Administration had costsharing for at least some individuals, but the DOJ prisoner health care services and Workers’
Compensation did not.9
The other two programs—Medicare and the Federal Employees Health Benefits Program—both
had cost-sharing for at least some services during the pandemic. The Federal Employees Health
Benefits Program encouraged, but did not require, the insurers to waive telehealth cost-sharing
associated with the treatment of COVID-19. However, most insurers waived cost-sharing either
for all telehealth services or for telehealth services that led to a COVID-19 diagnosis for at least a
portion of the first year of the pandemic. Medicare fee-for-service continued to require cost-sharing
during the pandemic; however, providers could waive cost-sharing for services provided
via telehealth.10

Four programs paid providers equivalent amounts for telehealth services and
in-person services
Medicare, TRICARE, and Workers’ Compensation programs paid providers equivalent amounts
for telehealth services and in-person services. Similarly, the Veterans Health Administration paid
equivalent amounts for telehealth services and in-person services when paying non-VA providers
in the community. This was a change for all of these programs except the Workers’ Compensation
programs, which paid providers equivalent amounts for these services prior to the pandemic.11
DOJ’s Federal Bureau of Prisons pays a salary to some providers to care for individuals in its
prisons; these providers do not receive a payment per service. Providers employed by the Veterans
Health Administration are paid a salary, as opposed to a payment per service. The Federal
Employees Health Benefits Program does not set payment rates.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

USE OF TELEHEALTH
INSIGHT: All selected programs in six federal agencies experienced
dramatic increases in the use of telehealth during the first year of the
pandemic compared to the year prior
All selected programs had large increases in the use of telehealth during the first year of the
COVID-19 pandemic—i.e., from March 2020 through February 2021—compared to the year
prior, from March 2019 through February 2020. With limited access to in-person care and many
programs expanding flexibilities for the use of telehealth, each program saw a significant uptick in
the use of telehealth from the year prior to the pandemic.

Approximately 37 million individuals used telehealth in the selected programs
during the first year of the pandemic
In total, approximately 37 million individuals used
telehealth services from March 2020 through February
2021 in the selected programs in six federal agencies.12
This was a dramatic increase from the year prior, when
approximately 3 million individuals used telehealth
services in these programs. Overall, the number of
individuals using telehealth in these programs was 13
times as high in the first year of the pandemic as in the
prior year. See Exhibit 3.
Two programs—Medicare and TRICARE—had the largest
increases, with over 80 times the number from the
prior year in Medicare, and over 70 times the number
in TRICARE. During the pandemic, Medicare allowed
individuals to use telehealth for a wide range of services
in different locations. Prior to the pandemic, generally only
Medicare beneficiaries in rural areas could use telehealth
services and beneficiaries were generally not allowed to
receive telehealth services from home. Similarly, TRICARE
expanded coverage for telehealth services during the
pandemic, including allowing for audio-only telehealth
services and waiving cost-sharing for telehealth services,
among other changes. See Exhibit 4.

Pandemic Response Accountability Committee

Exhibit 3: Across the selected
programs, 13 times as many
individuals used telehealth services
during the first year of the COVID-19
pandemic as in the prior year.
37 Million

3 Million
March 2019February 2020

March 2020February 2021

Source: Analysis of data from selected programs
in six federal agencies, 2022.

Insights on Telehealth Use and
Program Integrity Risks

Exhibit 4: The number of individuals who used telehealth during the pandemic was 13 times as
high as in the year prior in the selected programs.
Year prior to
the pandemic

First year of
the pandemic

Times
increase

Medicare

341,000

28 million

TRICARE

23,900

1.7 million

500

16,000

78,900

2.2 million

2.3 million

4.8 million

2,065

4,285

3 million

37 million

DOL Workers’ Compensation Programs
Federal Employees Health Benefits Program
Veterans Health Administration
DOJ prisoner health care services
Total

Source: Analysis of data from selected programs in six federal agencies, 2022.
Notes: The total represents the aggregated number of individuals who used telehealth in each program. Individuals who received
telehealth from more than one program may be counted multiple times. Numbers are rounded. Calculations of totals and increases
were conducted on unrounded numbers.
The number of individuals who used telehealth in the Veterans Health Administration includes those who used telehealth directly
from VA providers; it does not include data on individuals who received telehealth from non-VA providers in the community. In
addition, the numbers for the Federal Employees Health Benefits Program include data from the largest insurer, which represents
approximately 68 percent of individuals enrolled in all plans.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

The percentage of individuals using telehealth varied by program, with the highest
percentage at the Veterans Health Administration
Individuals used telehealth to varying
degrees during the pandemic in the selected
programs. The highest percentage of
individuals who used telehealth was in the
Veterans Health Administration.13 Almost 90
percent of veterans served by the program
used telehealth during the first year of the
pandemic. See Exhibit 5. Compared to the
other federal health care programs, the
Veterans Health Administration allowed for
greater access to telehealth prior to the
pandemic and then expanded flexibilities for
telehealth even further once the pandemic
began. For example, prior to the pandemic,
the Veterans Health Administration allowed
for both audio-video and audio-only telehealth
services and, during the pandemic, built
upon a program to lend veterans broadbandenabled devices so they could access
telehealth services.
In three other programs, about two in
five individuals used telehealth. In these
programs—the Federal Employees Health
Benefits Program, Medicare, and TRICARE—40
percent to 49 percent of the individuals they
served used telehealth during the first year
of the pandemic. These three programs had
limitations on access to telehealth prior to the
pandemic and then expanded access once
the pandemic began.
Telehealth was less common in Workers’
Compensation and DOJ prisoner health care
services. These programs differ from the
others. Workers’ Compensation covers care
only for work-related injury. Unlike the other
programs, it does not provide comprehensive
medical care for the individuals it serves.
Further, DOJ prisoners can directly receive
in-person care provided by staff working in the
facilities in which they are housed.

Pandemic Response Accountability Committee

Exhibit 5: Percentage of individuals using
telehealth in each program.

87%

Veterans Health
Administration

43%

Medicare

11%

DOL Workers'
Compensation
Programs

49%

TRICARE

40%

Federal Employees
Health Benefits
Program

DOJ prisoner
health care
services

Source: Analysis of data from selected programs in six federal
agencies, 2022.
Notes: The number of individuals who used telehealth in the
Veterans Health Administration includes those who used
telehealth directly from VA providers. In addition, the numbers
for the Federal Employees Health Benefits Program include
data from the largest insurer, which represents approximately
68 percent of individuals enrolled in all plans.

Insights on Telehealth Use and
Program Integrity Risks

In total, individuals in the selected programs used about 156 million telehealth
services during the first year of the pandemic
Individuals in Medicare used the most telehealth services, totaling 114.4 million services. In
contrast, the individuals in the DOJ prisoner health care services used about 6,000 telehealth
services during the first year of the pandemic. See Exhibit 6.
Exhibit 6: Individuals in the selected programs used about 156 million telehealth services
during the first year of the pandemic.
Medicare

114.4 million

Veterans Health Administration

27.1 million

Federal Employees Health Benefits Program

8.0 million

TRICARE

5.9 million

DOL Workers’ Compensation Programs

58,000

DOJ prisoner health care services

5,900

Total

156 million

Source: Analysis of data from selected programs in six federal agencies, 2022.
Notes: The number of telehealth services used in the Veterans Health Administration includes services provided directly by VA
providers; it does not include data on services provided by non-VA providers in the community. In addition, the numbers for the
Federal Employees Health Benefits Program include data from the largest insurer, which represents approximately 68 percent of
individuals enrolled in all plans.

Office visits with a primary care provider or specialist and behavioral health
services were the most common telehealth services in the selected programs
In most of the programs, office visits with a primary care provider or specialist and behavioral
health services (e.g., individual therapy, group therapy, and substance use disorder treatment)
accounted for the vast majority of telehealth services used by individuals in the selected programs.
For example, office visits and behavioral health services accounted for 93 percent of all telehealth
services in Workers’ Compensation; these same services accounted for 91 percent of telehealth
services in the Federal Employees Health Benefits Program.14 See Exhibit 7 for the three most
common service types by program. Because of differences in data, the service categories vary in
some programs.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

Exhibit 7: Top three most common types of telehealth services during the first year of the
pandemic in each program
First

Second

Third

Medicare

Office visits with primary
care or specialists

Virtual care services15

Behavioral health
services

TRICARE

Primary care

Mental health care

Specialty care

Federal Employees
Health Benefits
Program

Office visits with primary
care or specialists

Behavioral health
services

Physical therapy,
occupational therapy,
and speech therapy

Veterans Health
Administration

Primary care

Behavioral health
services

Specialty care

DOL Workers’
Compensation
Programs

Office visits with primary
care or specialists

Behavioral health
services

Physical therapy,
occupational therapy,
and speech therapy

DOJ prisoner health
care services

Psychiatry

Cardiology

Nephrology

Source: Analysis of data from selected programs in six federal agencies, 2022.
Notes: Because of differences in data and analysis, service categories are not the same across all agencies. For example, some
programs combine office visits for primary care and specialty care; others analyze these separately.
The DOJ OIG’s analysis includes only services provided in the Federal Bureau of Prisons by specialists and is broken out by
specialty of the provider, rather than category of service. In addition, the most common telehealth services in the Veterans Health
Administration are based on data on telehealth services provided directly by VA providers.

The total amount that the selected programs paid for telehealth services
exceeded $6 billion during the first year of the pandemic
During the first year of the pandemic, the selected programs in six federal agencies spent more
than $6.2 billion on telehealth services. Most of this spending was in Medicare, which accounted
for $5.1 billion. TRICARE and the Federal Employees Health Benefits Program accounted for an
additional $1 billion. See Exhibit 8.
This amount underestimates the total amount spent on telehealth services in these programs
because of data limitations in some programs. For example, at the time of this report, payment
information was available only for services provided by non-VA providers in the community, not for
services provided by VA providers. In addition, payment information is available only for Medicare
fee-for-service and not Medicare Advantage, which accounts for just under half of all telehealth
services used in Medicare during the first year of the pandemic.

Pandemic Response Accountability Committee

Insights on Telehealth Use and
Program Integrity Risks

Exhibit 8: The selected programs paid more than $6 billion for telehealth services during the
first year of the pandemic.
Medicare

$5.1 billion

Federal Employees Health Benefits Program

$646 million

TRICARE

$394 million

Veterans Health Administration

$62 million

DOL Workers’ Compensation Programs

$7.3 million

DOJ prisoner health care services

$444,800

Total

$6 billion

Source: Analysis of data from selected programs in six federal agencies, 2022.
Notes: The amount spent on telehealth services is an underestimate because of limitations in the data. For example, the amount the
Veterans Health Administration spent is only for services that were provided by non-VA providers in the community.

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PROGRAM INTEGRITY
INSIGHT: OIGs identified several program integrity risks associated
with billing for telehealth services that were similar across multiple
programs
The six OIGs identified risks related to billing and payment for telehealth services in the selected
programs. Some of the OIGs also identified specific providers with telehealth billing practices that
raise concern and may indicate fraud, waste, or abuse.

OIGs identified risks involving inappropriate billing for the highest, most expensive
level of telehealth services
Billing for higher levels of services than medically necessary—or billing for levels of services that
were not rendered—to inappropriately increase payment amounts is a scheme that is sometimes
called “upcoding.”
Three OIGs—HHS, OPM, and DOL—identified providers
who billed for the highest level of telehealth services
for a large proportion of their telehealth services.
For example, the HHS OIG identified more than 300
Medicare providers who billed for telehealth services
at the highest, most expensive level every time,
totaling approximately $5.2 million.

Exhibit 9: Examples of program integrity
risks associated with billing of telehealth
services

In another example of this type of risk, the DOL
OIG identified a provider who treated an individual
twice weekly for 45-50 minutes, including phone
consultations, but used an inappropriate billing code
that represented 60 minutes of psychotherapy.16
The billing record showed that the provider had
consistently used the 60-minute billing codes for most
of his cases.

• Duplicate billing of the same service

• “Upcoding” telehealth visits by billing for
visits longer than they lasted, or providing
basic services and then billing for more
complex visits
• Billing for services that were not provided or
not medically necessary
• Billing for services that are seemingly not
appropriate for telehealth or ineligible for
telehealth
• Ordering unnecessary durable medical
equipment, supplies, or laboratory tests
associated with a telehealth visit

A fourth OIG—VA OIG—identified an increased volume
of telehealth claims billed at the high-intensity
service level during the first year of the pandemic. The providers who billed these claims were paid
approximately $10.7 million. In addition, the DoD OIG found that TRICARE also identified billing for
high levels of service as a potential fraud risk and established a process to identify providers who
billed for the highest level of telehealth services for a large proportion of their telehealth services.

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OIGs identified risks related to duplicate claims and high-volume billing
Duplicate claims | OIGs identified concerns related to providers billing twice for the same service.
Billing in this manner may indicate that providers are intentionally submitting duplicate claims to
increase their payments.
Notably, the HHS OIG identified 138 providers who repeatedly billed both Medicare fee-for-service
and a Medicare Advantage plan for the same telehealth service. The VA OIG also identified duplicate
claims for the same telehealth service in the VA’s programs. The VA paid approximately $1.5 million
for about 14,000 possible duplicate telehealth claims involving about 1,900 providers. The DoD OIG
also found that TRICARE identified these types of claims as a potential risk.
High-volume billing | In addition, OIGs had concerns about high-volume billing, which may indicate
that providers are billing for services that are not provided or not necessary. These concerning
billing practices, along with duplicate claims and upcoding, also occur with in-person services.
Specifically, three OIGs—HHS, OPM, and VA—identified providers who billed for telehealth services
for an unusually high number of hours per visit or per day. For example, the HHS OIG identified 86
providers who billed for a high average number of hours of telehealth services per visit. Additionally,
the VA paid approximately $578,000 for claims (out of a total of about $62 million spent) that were
associated with high usage days—i.e., days on which a provider billed for more than 18 hours of
telehealth services—from March 2020 through February 2021. OIGs also identified providers who
billed telehealth services for an unusually high number of individuals. The DoD OIG also found that
TRICARE identified this type of billing as a potential fraud risk.

OIGs identified risks related to billing for services that were seemingly not
appropriate for telehealth or ineligible for payment as a telehealth service
OIGs identified risks related to billing telehealth for inappropriate services. Specifically, the OPM
OIG identified one provider who billed wound debridement—the removal of dead or unhealthy
skin from a wound—via telehealth, and a different provider who submitted a telehealth claim for
anesthesia. The DOL OIG identified a provider who billed for acupuncture via telehealth. Two OIGs—
HHS and DoD—also identified providers who billed for telehealth services and facility fees, which
would indicate that the patient and provider were in the same location at the time of the telehealth
visit. These examples raise concern, as they may indicate that to inappropriately maximize their
payments for each visit, providers are billing for services that are not being provided appropriately
or billing for telehealth services that never occurred.

OIGs also identified risks related to ordering unnecessary durable medical
equipment or laboratory tests associated with telehealth visits
In the last few years, several large health care fraud investigations have involved telemarketing
schemes, often referred to as telefraud.17 In one example, a laboratory owner paid kickbacks to
an individual to arrange for telehealth providers to order genetic testing on behalf of Medicare

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Insights on Telehealth Use and
Program Integrity Risks

beneficiaries.18 This individual then gave Medicare beneficiary information to these providers, which
they could use to bill for telehealth services. In some similar cases, the sham telehealth visits were
billed to Medicare.19 In several other cases, the providers did not bill for sham telehealth visits.
Instead, the perpetrators billed fraudulently only for other items or services, like durable medical
equipment or genetic tests.
In a separate evaluation, the HHS OIG identified 67 providers who, for a large proportion of their
Medicare beneficiaries, ordered durable medical equipment after they billed for telehealth visits.
This type of billing raises concern that 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.
The DOL OIG also reported concerns related to billing for durable medical equipment. In one
example, the DOL OIG identified a provider who had an uptick in durable medical equipment orders
after the provider moved to telehealth, and as a result, this provider accounted for over threequarters of all spending in the Workers’ Compensation programs for one type of durable medical
equipment.

INSIGHT: OIGs found limited information about the impact of telehealth
on quality of care, which has implications for the care provided to
individuals and program integrity
OIGs report that there is limited information about the impact of telehealth on quality of care.
Federal health care programs need information on how telehealth affects quality of care to
help ensure that individuals served by these programs receive safe and effective health care.
Additionally, information on quality of care can help programs make decisions about which services
may be best suited for telehealth versus those that are better suited for in-person care. It can also
help identify program integrity concerns related to the nature of the care provided, such as whether
it is properly supervised or provided by appropriate staff.
Three OIGs—HHS, OPM, and DOJ—found that little is known about quality of care related to
telehealth services. The HHS OIG further noted the need to evaluate quality of care, especially
as it relates to audio-only telehealth services. The OPM OIG noted that, while OPM does conduct
annual quality of care assessments, these assessments do not include any telehealth-specific
measures. In addition, just one of the contracted insurers it surveyed indicated that it had a plan to
assess quality. The DOJ OIG found that the lack of telehealth policies and robust data on telehealth
services could present barriers to the programs’ ability to assess quality of care.
Furthermore, the DoD OIG found that TRICARE had limited information about the impact of
telehealth services on quality of care. For example, one of two TRICARE contractors included in the
DoD OIG’s review does not track quality of care issues specific to telehealth. In addition, the VA OIG
noted the need for ongoing studies to evaluate the effect of telehealth on quality of care during the
COVID-19 pandemic. These studies could evaluate appropriateness of care; admission rates; delay
in diagnoses; patient satisfaction; barriers to care; and standardized quality metrics and guidelines.

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Despite limited information, OIGs identified some specific
concerns related to the impact of telehealth on quality of
care. For example, one of TRICARE’s contractors identified
89 potential quality issues related to telehealth during
the first year of the pandemic, up from seven issues the
year before. In the Workers’ Compensation programs,
providers allegedly rendered services without appropriate
supervision, potentially affecting the quality of care
provided.

Example of a concern about quality
of care
• The DOL OIG identified a provider who
allegedly performed medical evaluations
via telehealth using untrained and
unsupervised technicians.

INSIGHT: OIGs found that programs lack some data necessary for
oversight of telehealth services
Most OIGs found that the selected programs need additional data to oversee billing for telehealth
services and to better understand how telehealth is used in these programs. Complete and reliable
data on telehealth services are critical to oversight and protecting against program integrity risks.
These data are also important to assessing the impact of telehealth on quality of care.
Notably, the DOJ OIG found that DOJ prisoner health care services lack comprehensive data on
telehealth services and, as a result, DOJ is unable to calculate the total cost of telehealth services
or determine the total number of telehealth services
delivered to prisoners in its custody. For example, DOJ
Examples of data needed to oversee
currently lacks a central claims system for the Federal
telehealth services
Bureau of Prisons that can track telehealth services and
associated costs. This and other limitations affect DOJ’s
• DOJ prisoner health care services lack
ability to fully assess the use of telehealth for prisoners in
comprehensive data on telehealth
federal custody.
services.

The HHS OIG found that Medicare lacks specific data on
audio-only telehealth services. Medicare can only identify
the use of audio-only for six services even though 86
other services can be provided audio-only. This lack of
data inhibits HHS’s ability to assess the use of audioonly telehealth services on quality of care and program
integrity.

• Medicare lacks data on some providers
who render telehealth services.
• DoD’s oversight data does not always
distinguish telehealth from in-person
care.

The HHS OIG also found that Medicare does not collect data about some of the providers who
render services. A 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. This lack of
transparency prevents HHS from determining which provider rendered a telehealth service to a
beneficiary, which is critical to oversight.
The DoD OIG found that TRICARE’s oversight data do not always distinguish telehealth services
from in-person services, hindering its ability to monitor telehealth. For example, audits of claims

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Program Integrity Risks

and reports on denials from TRICARE contractors are aggregated to include both in-person and
telehealth services, preventing the DoD from analyzing data specific to telehealth services.
The DOL OIG also found instances in which Workers’ Compensation data inaccurately identified
telehealth services as in-person services, raising concern that telehealth providers may be
submitting bills for telehealth services without the appropriate place of service code and/or
modifier.

INSIGHT: The selected programs in the six federal agencies have some
safeguards in place to oversee telehealth services, but additional
safeguards could strengthen program integrity
While all selected programs have processes to oversee telehealth services, there are opportunities
to strengthen monitoring and target oversight to ensure program integrity in each program. Doing so
will help to realize the benefits of telehealth while minimizing the risk of fraud, waste, and abuse.

Program integrity safeguards generally include data analysis, claims edits,
medical reviews, and/or audits
All selected programs have some type of program integrity
safeguards in place. Although these safeguards vary by
program, they generally include data analysis, claims edits,
medical reviews, or audits. These safeguards are similar to
safeguards that agencies use to oversee in-person claims
and are sometimes specific to telehealth.

OIG Hotlines
In addition to the programs’
efforts, each of the six
OIGs operate hotlines where providers
and members of the public can report
complaints related to health care fraud,
waste, and abuse, including those related
to telehealth services.

All selected programs use data analysis to oversee
telehealth. Generally, data analysis identifies concerning
billing patterns in claims data. For example, DOJ’s United
States Marshals Service’s National Managed Care
Contract contractor for prison medical care has an anti-fraud program that includes identification
of unusual patterns of care, over-utilization of services, suspect billing practices, and other unusual
patterns using available data. Similarly, the Veterans Health Administration receives reports from its
contractors (or third-party administrators) that include information on claims that may be suspicious
for telehealth services provided in the community.
Medicare, the Federal Employees Health Benefits Program, TRICARE, and Workers’ Compensation
also use claims edits and post-payment reviews or audits to safeguard against program integrity
risks. Claims edits reject payments for claims that do not meet certain program requirements.
Post-payment reviews and audits generally involve a higher level of scrutiny for a sample of claims
to ensure that they meet program requirements. For example, Medicare conducts post-payment
reviews to determine if billed services were medically necessary. In addition, insurers in the Federal
Employees Health Benefits Program typically have edits in place to identify duplicate payments,
medical necessity reviews, and upcoding.

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Insights on Telehealth Use and
Program Integrity Risks

Additional safeguards could strengthen program integrity for telehealth
OIGs identified several opportunities to strengthen oversight of telehealth services. Although the
extent and specific types of additional safeguards that could strengthen each program vary, these
safeguards commonly involve monitoring, billing controls, education, and data. A number of OIGs
also identified the need for more information related to quality of care. These common safeguards
are described below. For information about the specific safeguards needed in each program, see
the individual sections.

» Programs could conduct additional and ongoing monitoring of telehealth services. Federal
health care programs could conduct additional, targeted monitoring of telehealth services
to identify program integrity risks. This monitoring could include data analysis focused on
the program integrity risks identified in this report, as well as other risks the programs deem
appropriate.

For example, the HHS OIG recommends that Medicare closely monitor telehealth services on
an ongoing basis to identify providers who pose a risk to the program and conduct targeted
reviews of these providers. These reviews could include close monitoring of providers’ billing
patterns and reviews of their medical records, as appropriate. These reviews would build on
safeguards currently in place and could be used to recover inappropriate payments, place
certain providers on pre-payment review, initiate fraud investigations, or develop additional
claims processing edits, as necessary.

» Programs could develop additional billing controls to prevent inappropriate payments for
telehealth services. Federal health care programs could develop additional billing controls,
such as pre-payment edits, to prevent inappropriate payments for telehealth. These controls
could address the program integrity risks identified in this report and be tailored to each
program, as needed.

For example, the OIGs from both DoD and OPM suggest creating controls to prevent telehealth
payments for services that are not appropriate to be delivered using telehealth. The OPM OIG
suggests that OPM develop and maintain a list of services for which the Federal Employees
Health Benefits Program providers may be reimbursed when performed via telehealth and
insurers should be required to place edits in their claims systems that will check telehealth
claims against this list. The DoD OIG recommends that TRICARE establish controls to prevent
payments for improperly coded telehealth claims, among other controls.

» Programs could conduct efforts to educate providers and individuals about telehealth

services. Federal health care programs could conduct additional education for providers and
individuals about telehealth services. Such efforts could help ensure that providers know how
to correctly bill for telehealth services. These efforts would also help ensure that individuals
served by federal health care programs are aware of telehealth policies as well as how to
report any suspicious billing to the programs or the OIG hotlines.
For example, the HHS OIG recommends that CMS conduct additional education to providers
on appropriate billing for telehealth services. The HHS OIG recommends that CMS target
specific providers with high levels of inappropriate billing for telehealth services and provide

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Insights on Telehealth Use and
Program Integrity Risks

them with additional education about the telehealth services inappropriately billed and the
Medicare guidelines that should have been followed. Further, the OPM OIG suggests that OPM
issue guidance to its Federal Employees Health Benefits Program’s carriers and members on
telehealth-related concerns.

» Programs could collect additional data to support better oversight of telehealth services.

Federal health care programs could collect additional data to improve program integrity efforts
related to telehealth services and help safeguard the programs against fraud, waste, and
abuse. These additional data could address concerns related to the lack of data identified in
this report and other concerns, as appropriate.

For example, to address concerns that DOJ prisoner health care services lacked key data,
the DOJ OIG noted that DOJ should strengthen its collection of telehealth data and conduct
additional research to safeguard program integrity. Additionally, the HHS OIG recommends that
Medicare collect specific data to improve oversight of telehealth, including data on audio-only
telehealth services and data to indicate when services are provided “incident to” supervising
practitioners. Improving transparency of “incident to” services would strengthen Medicare’s
program integrity efforts and enable oversight agencies to conduct more detailed monitoring
at the provider level.20 Comprehensive data on telehealth services are critical for safeguarding
federal health care programs.

» Programs could collect and review information about the impact of telehealth services

on quality of care. Programs could collect and evaluate data on the impact of telehealth
services on quality of care. For example, the VA OIG noted that ongoing study is needed on
the impact of telehealth on quality of care during the pandemic, such as appropriateness of
care, readmission rates, delay in diagnoses, patient satisfaction, barriers to care, standardized
quality metrics, and guidelines.
Federal health care programs could then use this information on how telehealth affects
quality of care to help ensure that individuals served by these programs receive high-quality
care. Additionally, information on quality of care can help programs make decisions about
which services may be best suited for telehealth versus those that are better suited for inperson care. Further, this information can protect the integrity of telehealth services provided
through these federal programs, as some practices pose concerns for both quality and
program integrity. For example, if an unqualified practitioner provides and bills for services
via telehealth, individuals may receive substandard care and the programs may be paying
inappropriately for those services. Programs could also consider information on quality of care,
as well as information about the impact of telehealth on program integrity and access to care,
as they consider long-term policies related to telehealth.

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Conclusion
The changes to telehealth policy, along with the dramatic increase in the use of telehealth, during
the first year of the COVID-19 pandemic underscore the importance of identifying program integrity
risks associated with telehealth services and of identifying ways to safeguard the program against
fraud, waste, and abuse.
This report provides insights about the nature of telehealth and its use across selected programs
in six federal agencies during the first year of the pandemic, as well as insights about the program
integrity risks associated with telehealth and safeguards that could strengthen oversight. Although
this report does not represent a comprehensive review of telehealth services in all federal health
care programs, it provides insights on the populations covered by a variety of federal health care
programs.
The insights summarized below are intended to help stakeholders—such as Congress; federal and
state agencies; and health care organizations—understand how the expanded use of telehealth
during the COVID-19 pandemic helped individuals access health care when there were challenges
to accessing care in person and how best to use telehealth in the future while safeguarding against
fraud, waste, and abuse.
• The selected programs in six federal agencies took various steps—including issuing new
policies and guidance—to make telehealth available during the pandemic.
• The selected programs provided relatively similar coverage of telehealth services during the
pandemic, including covering a range of telehealth services.
• All of the selected programs experienced dramatic increases in the use of telehealth during
the first year of the pandemic.
• OIGs identified several program integrity risks associated with billing for telehealth services
that were similar across multiple health care programs, such as risks involving inappropriate
billing for the highest, most expensive level of telehealth services and risks related to duplicate
claims and high-volume billing.
• OIGs found limited information about the impact of telehealth on quality of care.
• OIGs found that programs lack some data necessary for oversight of telehealth services.

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• The selected health care programs have some safeguards in place to oversee telehealth
services, but additional safeguards could strengthen program integrity. For example:

» Programs could conduct additional monitoring of telehealth services.
» Programs could develop additional billing controls to prevent inappropriate payments
for telehealth services.

» Programs could conduct efforts to educate providers and individuals about telehealth
services.

» Programs could collect additional data related to telehealth services.
» Programs could collect and review information about the impact of telehealth services
on quality of care.

These insights demonstrate the importance of ensuring the benefits of telehealth are realized while
minimizing the risk in an effective and efficient manner.

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GENERAL METHODOLOGY
The PRAC Health Care Subgroup consists of six OIGs that oversee agencies that provide or are
involved with the provision of health care services. These agencies are HHS, OPM, DOL, VA, DoD,
and DOJ. Each of the six OIGs selected a health care program within its agency for which it could
obtain reasonably reliable data on the use of telehealth services for the first year of the COVID-19
pandemic, from March 1, 2020, to February 28, 2021, as well as the year prior to the pandemic,
from March 1, 2019, to February 29, 2020.

Data Collection and Analysis
Each OIG collected and analyzed data and information from its selected health care program. The
data that the OIGs collected addressed the following topics:
1. To what extent did the selected programs in six federal agencies make telehealth services
available to individuals during the pandemic?
2. To what extent did individuals served by these selected programs use telehealth services
during the first year of the pandemic?
3. What types of program integrity risks are associated with the use of telehealth services?
4. What types of data and safeguards could strengthen oversight?
Data collection | Because the selected health care programs vary, OIGs relied on different
sources of information to collect the necessary data. OIGs collected data about telehealth policies,
telehealth use, and related program integrity risks using claims and other health care encounter
data; using surveys; and reviewing federal statutes, agency guidance, and policy manuals, among
other sources.
To ensure a level of standardization and consistency, the HHS OIG, in collaboration with the other
participating OIGs and the PRAC, developed a framework to guide data collection and analysis.
Each OIG determined which data sources to use in its analyses and coordinated as necessary with
officials from its federal health care program to obtain this data. For the program integrity section
of the report, the OIGs focused on issues related to billing and payment risks; quality of care; data;
and safeguards.21
Data analysis | Each OIG analyzed telehealth data for its selected health care program and
determined key information about the use of telehealth and related program integrity risks. The
HHS OIG then reviewed the findings from all selected health care programs to provide broader
insights and shared the insights with the other OIGs for review. For agency-specific details about the
data and analysis, refer to the methodology section in the appendix.

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Data availability for each of the selected health care programs
Medicare | Medicare information included in this review is based on data on telehealth services
provided by physicians and non-physician practitioners for all Medicare beneficiaries in Medicare
fee-for-service and Medicare Advantage. While information about the use of telehealth is available
for all beneficiaries, payment information is not available for beneficiaries enrolled in Medicare
Advantage.
TRICARE | TRICARE information included in this review is based on data for all TRICARE
beneficiaries who are enrolled in TRICARE Prime and TRICARE Select plans in the continental United
States. There is another TRICARE Program, called TRICARE for Life—which is Medicare wraparound
coverage for beneficiaries who have Medicare Parts A and B—that was not included in this review.
In addition, many TRICARE participants obtain telehealth services through Military Treatment
Facilities, which were not part of this review.
Federal Employees Health Benefits Program | The Federal Employees Health Benefits Program
information included in this review is primarily based on Federal Employees Health Benefits
Program policies, as well as survey responses from 10 selected Federal Employees Health Benefits
Program insurance carriers. Information about the use of telehealth in the Federal Employees
Health Benefits Program is based on data from the Federal Employees Health Benefits Program’s
largest insurance carrier, which operates nationwide and accounts for approximately 68 percent of
all individuals enrolled in the Federal Employees Health Benefits Program.
Veterans Health Administration | The Veterans Health Administration provides direct care,
including telehealth services, to enrolled veterans. The Veterans Health Administration also
reimburses third-party administrators that process claims and pay non-VA providers under the
Veterans Community Care Program. Data for both programs are included in this review.
Office of Workers’ Compensation Programs | Workers’ Compensation information included in
this review is based on data for individuals in the Federal Employees Compensation Act program,
the Black Lung program, and the Energy program. A fourth Workers’ Compensation program, the
Longshore program, is not included in this review.
DOJ prisoner health care services | Federal prisoner program information included in this review
is based on data for individuals in the Department of Justice’s Federal Bureau of Prisons and
individuals in the custody of the United States Marshals Service. The data about the types of
services used via telehealth and the payment data for the Federal Bureau of Prisons are incomplete
because of data limitations. Data from the United States Marshals Service are also incomplete and
include only information from its National Managed Care Contract contractor for prisoner medical
care.

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LIMITATIONS
This report does not present a comprehensive review of the use of telehealth across all health
care programs either provided through or administered by the Federal Government. The data
and insights are limited to the selected federal health care programs. There are other federal;
state; local; and private providers and payors of telehealth services. Some individuals within the
selected federal health care programs may have received telehealth services through one of these
alternative sources. Further, some individuals may be enrolled in more than one of the selected
federal health care programs and could have received telehealth services from multiple programs.
In addition, this report was designed to identify program integrity risks. None of the examples of
risk identified in this report confirm that a particular provider is engaging in fraudulent or abusive
practices. Any determination of fraud or an overpayment would require additional investigation.
For agency-specific limitations, see each OIG’s detailed methodology in the corresponding appendix.

STANDARDS
Each OIG 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 (CIGIE). Each
OIG followed its own processes to ensure that its contributions to this report met CIGIE standards
and provided an attestation to the PRAC stating that it met those standards.

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GLOSSARY
Audio-only service: A telehealth service that is provided using a two-way, real-time audio connection
that does not include video.
Audio-video service: A telehealth service that is provided using a two-way, real-time audio and video
connection.
Behavioral health services: Health care services to diagnose, evaluate, or treat mental health or
substance use disorders.
Cost-sharing: The out-of-pocket costs for a covered service that the individual is responsible for
paying. Cost-sharing usually includes deductibles, coinsurance, copayments, or similar charges.
Durable medical equipment: Equipment and supplies ordered by a health care provider for
everyday or extended use. Examples include oxygen equipment, wheelchairs, crutches, or blood
testing strips for people with diabetes.
Edits: Automated checks coded into a claims processing system that are designed to verify that
health insurance claims are coded correctly or to flag the claim for further review.
Facility fee: A fee billed by a facility—such as a hospital or physician’s office—for hosting a patient
during a telehealth service that is provided by a practitioner who is at a separate location. Also
referred to as an “originating site facility fee.”
Fee-for-service: A reimbursement method in which doctors and other health care providers are paid
for each service performed.
“Incident to” billing: A Medicare billing practice that allows for 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.
Insurance carriers: A carrier is another name for insurance company. The terms insurer, carrier,
and insurance company are generally used interchangeably, and describe a voluntary association
or organization that is lawfully engaged in providing, delivering, paying for, or reimbursing the cost of
health care services under contracts providing a plan of health insurance, health benefits, or health
services.
Modifier: Two-digit numbers, characters, or alpha-numeric combinations that provide additional
information on a claim. For example, some modifiers are used to identify telehealth services.
Office visit: An appointment with a primary care provider or specialist, usually for the evaluation or
management of a patient’s health.
Place of service code: Two-digit codes on health care claims to indicate the setting in which a
service was provided.

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Remote patient monitoring: Non-face-to-face monitoring and analysis of physiologic factors to
understand a patient’s health status—for example, remote monitoring of oxygen saturation levels,
blood pressure, and weight. Also known as remote physiologic monitoring.
Telefraud: Telemarketing schemes that generally involve a phone call or other remote interaction
with a patient to order or prescribe medically unnecessary testing, equipment, or prescriptions but
do not involve billing for a telehealth service.
Telehealth company: A company that employs practitioners to provide on-demand telehealth
services to patients. Unlike other providers, telehealth companies do not offer in-person services.
Telehealth service: A health care service that is provided remotely using technology between
a provider and a patient. This report focuses on the use of telehealth between a patient and a
provider; it does not include provider-to-provider interactions.
Upcoding: Billing for a health care service at a higher level of complexity or duration than was
provided or needed.
Virtual care services: A type of telehealth service that is always provided remotely, unlike other
types of services that can also be provided in-person. Examples of virtual care services include
telephone calls with a provider or interactions via an online patient portal, and remote monitoring,
such as weight and blood pressure checks.

Pandemic Response Accountability Committee

Department of Health and
Human Services

Medicare
HHS’s Centers for Medicare & Medicaid Services (CMS) administers the Medicare program, which
provides health care coverage for about 66 million beneficiaries who are age 65 or older, are
disabled, or have end-stage renal disease. Medicare covers inpatient and outpatient services—e.g.,
hospital and physician services—for enrolled patients.
Beneficiaries may enroll in Medicare fee-for-service or Medicare Advantage. CMS sets payment
rates for services provided in Medicare fee-for-service. To bill Medicare fee-for-service, providers
must meet certain requirements, such as having the appropriate licensure, and be enrolled in the
program. Beneficiaries enrolled in Medicare fee-for-service are generally responsible for 20 percent
of the payment rates. Medicare Advantage plans are offered by private companies and have the
flexibility to create provider networks and offer extra benefits, including additional telehealth
services.
Scope of HHS Review: This review describes Medicare telehealth services provided by physicians
and non-physician practitioners.22 Medicare telehealth services refer to services that are provided
remotely using technology between a provider and a beneficiary.23 This review includes data
on telehealth services used by beneficiaries enrolled in Medicare fee-for-service and Medicare
Advantage during the first year of the pandemic (from March 2020 through February 2021) and the
year prior (from March 2019 through February 2020). See Appendix A for HHS OIG’s methodology.

MEDICARE TELEHEALTH POLICY CHANGES DURING THE PANDEMIC
In March 2020, Congress, HHS, and CMS took a number of actions to temporarily expand access
to telehealth for Medicare beneficiaries.24 These actions allowed Medicare beneficiaries to use
telehealth for a wide range of services. In addition, the actions also temporarily lifted restrictions on
where Medicare beneficiaries could receive telehealth and changed the payment rates to providers.
(See Exhibit 1 below for key policy changes during the pandemic.)25
Services: Beginning in March 2020, CMS temporarily expanded the types of services that Medicare
beneficiaries could receive via telehealth, increasing the number from 118 to 264. These included
services such as office visits; behavioral health services; nursing home visits; and physical,
occupational, and speech therapy.

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CMS also allowed certain services to be provided audio-only, rather than requiring audio-video.
These services include office visits and behavioral health services, among others. Prior to the
pandemic, audio-video was required for the delivery of almost all telehealth services.26
Exhibit 1: Key Differences in Medicare Telehealth Services Prior to and During the COVID-19
Pandemic

During the Pandemic

Prior to the Pandemic
Patients could receive 118 types
of services via telehealth.

$ $

Patients could receive 264 types
of services via telehealth.

Under most circumstances
audio-video was required.

Patients could receive many
telehealth services using
either audio-video
or audio-only.

Most patients were limited to
receiving telehealth at health
care facilities in rural areas.

Patients could receive
telehealth from home
and in both urban and
rural areas.

Providers were generally paid less
than in-person services.

were generally paid the
$ $ Providers
same rate as in-person services.

Only certain providers could
provide telehealth.

Any provider could
provide telehealth.

For certain services, providers could
provide telehealth services only to
patients with whom they had an
established relationship.

For certain services that were
limited to established patients prior
to the pandemic, providers could also
provide them to new patients.

Source: HHS OIG review of CMS policy, 2022.

Patients and Providers: During the pandemic, Medicare beneficiaries could access telehealth
services regardless of their geographic location.27 In addition, beneficiaries were allowed to
receive telehealth services from any setting, including from home. Prior to the pandemic, Medicare
beneficiaries could in most cases use telehealth from only certain medical facilities located in rural
areas, such as rural health clinics.

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During the pandemic, CMS also allowed any physician or non-physician practitioner who is eligible
to bill Medicare for services to provide telehealth services. Prior to the pandemic, only certain types
of practitioners were allowed to bill for telehealth services.
Providers were also permitted to provide telehealth to new patients, in addition to existing patients.
For certain services prior to the pandemic, providers could only provide telehealth services to
patients with whom they had an established relationship.
Payment Rates: CMS also changed payment rates for many telehealth services during the
pandemic, making them the same as payment rates for in-person services. Prior to the pandemic,
telehealth services were generally paid at lower rates than in-person services.
Patient cost-sharing for telehealth did not change during the pandemic. They were responsible for
20 percent of the payment rates, the same rate as prior to the pandemic.28

TELEHEALTH USE DURING THE PANDEMIC
During the first year of the pandemic, over 28 million Medicare beneficiaries used
telehealth services
During the first year of the pandemic—i.e., from March 2020 through February 2021—more than
28 million Medicare beneficiaries used a telehealth service.29 These beneficiaries represented 43
percent of the 66 million beneficiaries enrolled in Medicare, or about 2 in 5 Medicare beneficiaries.
This is a dramatic increase from the prior year, when less than 1 percent of Medicare beneficiaries—
approximately 341,000 in total—used telehealth. See Exhibit 2.

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Exhibit 2: Key Differences in Beneficiary Use of Medicare Telehealth Services Prior to and
During the COVID-19 Pandemic

Prior (March 2019 -- February 2020)

During (March 2020 -- February 2021)

Less than 1%
of patients used
telehealth services

43% of patients
used telehealth services

Patients received
1.3 million services
via telehealth

Patients received
114.4 million services
via telehealth

Medicare paid over
$66.4 million for telehealth
services for patients enrolled
in Medicare fee-for-service

Medicare paid over
$5.1 billion for telehealth
services for patients enrolled
in Medicare fee-for-service

Source: HHS OIG analysis of Medicare data, 2022.

Beneficiaries used 88 times more telehealth services during this time period than
they used in the prior year
In total, Medicare beneficiaries used 114.4 million telehealth services during the first year of
the pandemic, i.e., from March 2020 through February 2021. This amounts to 88 times more
telehealth services than the prior year.
About half of these telehealth services (60.1 million in total) were used by beneficiaries enrolled
in Medicare fee-for-service. In total, Medicare paid over $5.1 billion for telehealth services for
beneficiaries enrolled in Medicare fee-for-service, 76 times more than what it paid in the year
prior.30

Medicare beneficiaries most commonly used telehealth
for office visits, virtual care services, and behavioral
health services
Together, these three service types accounted for 90 percent of all
telehealth services during the first year of the pandemic. Office visits—
routine appointments with primary care providers or specialists—
accounted for 48 percent of all telehealth services. Virtual care
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Almost half of all
telehealth services
were office visits,
which are routine
appointments with a primary
care provider or specialist.
Source: HHS OIG analysis of Medicare
data, 2022.

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services, such as telephone calls with a provider or interactions via an online patient portal,
accounted for 30 percent of all telehealth services. Behavioral health services accounted for about
12 percent of all telehealth services. Behavioral health services include individual therapy, group
therapy, and substance use disorder treatment, among others. Other types of telehealth services
included nursing home visits; preventive services; and physical, occupational, and speech therapy.

Most Medicare beneficiaries received telehealth services only from providers with
whom they had an established relationship
In total, 84 percent of beneficiaries received all their telehealth services during the pandemic
from providers with whom they had an established relationship.31 These beneficiaries had an inperson visit with their provider an average of 4 months prior to their telehealth service. Prior to the
pandemic, Medicare required an established relationship between a beneficiary and provider for
certain telehealth services.

At least 12 million Medicare beneficiaries used
audio-only telehealth services; the vast majority of
these beneficiaries used them exclusively
During the first year of the pandemic, a total of 12.7 million
Medicare beneficiaries, or 19 percent of all beneficiaries, used
one of six telehealth services available only via telephone.32
These six audio-only services include telephone calls with
a provider to discuss a beneficiary’s medical condition. The
vast majority of these beneficiaries did not use any audiovideo telehealth services, which may suggest that they have a
preference for audio-only telehealth services or, that they face
barriers to using audio-video telehealth. See Exhibit 3.
It is important to note that an additional 86 telehealth services
are available either as audio-only or audio-video, but Medicare
data do not distinguish between the two.33 Therefore, the total
number of beneficiaries who used any audio-only services during
the first year of the pandemic is higher than 12.7 million.

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Exhibit 3: Most beneficiaries
who used audio-only services
did not use any audio-video
telehealth services

93% of
beneficiaries
who used audioonly services did
so exclusively

Source: HHS OIG analysis of Medicare
data, 2022.

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PROGRAM INTEGRITY RISKS RELATED TO TELEHEALTH SERVICES
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 and ensure quality of care.
This section highlights program integrity risks related to billing, quality of care, and data, as well as
needed safeguards for telehealth services.34 We focus on different types of billing that providers
may use to inappropriately bill for telehealth services and that shed light on potential methods
specific to telehealth for safeguarding the program and protecting beneficiaries.

Program Integrity Risks Related to Billing
Data analyses provide insight into different
types of billing for telehealth services that
may indicate fraud, waste, or abuse and
identifies providers whose billing poses a
high risk to Medicare

Exhibit 4: Program Integrity Measures
To identify telehealth providers whose billing for
telehealth services poses a high risk to Medicare,
the HHS OIG developed seven measures based
on analysis and input from OIG investigators:
• billing telehealth services at the highest,
most expensive level every time;

HHS OIG data analyses of Medicare telehealth
services shed light on different types of billing that
providers may use to inappropriately maximize their
Medicare payments for telehealth services.35 With
input from OIG investigators, we developed seven
measures to identify providers whose billing may
indicate fraud, waste, or abuse.36 See Exhibit 4 for a
list of these measures.
Using these measures, we identified over 1,700
providers whose billing for telehealth services 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,
some providers billed telehealth services at the
highest, most expensive level every time. In these
cases, providers may be delivering higher levels
of services than medically necessary or billing for
levels of services that were not rendered—a scheme
that is sometimes called “upcoding.” In other cases,
providers billed for telehealth services for a high

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• billing telehealth services for a high number
of days in a year;
• billing a high average number of hours of
telehealth services per visit;
• billing telehealth services for a high number
of beneficiaries;
• billing for a telehealth service and ordering
medical equipment for a high proportion of
beneficiaries;
• billing both Medicare fee-for-service and
a Medicare Advantage plan for the same
service for a high proportion of services; and
• billing both a telehealth service and a
facility fee for most visits.

Source: HHS OIG analysis of Medicare data, 2022.

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number of days a year. Billing in this manner may indicate that the provider is billing for services
that were not provided.

Hotline complaints described similar
billing schemes
The HHS OIG operates a hotline where
providers and members of the public can report
complaints related to health care fraud, waste,
and abuse, including those related to telehealth
services. Complaints related to telehealth
describe similar concerns to those discussed
above, such as complaints about services not
rendered and services provided that were not
medically necessary. See Exhibit 5.

Investigations raise concerns about
kickback schemes involving telehealth

Exhibit 5: Examples of complaints received
specific to telehealth include:
• providers instructing staff to “cold call”
beneficiaries via telephone and bill for a
telehealth visit;
• “upcoding” telehealth visits by billing for visits
longer than they lasted, or providing basic
services and then billing for more complex
visits;
• billing for services not rendered to the patient
• ordering unnecessary equipment, supplies, or
lab tests after a telehealth visit;

In the last few years, the HHS OIG has
• billing for services that were not medically
necessary; and
conducted several large investigations that
involved telemarketing schemes, referred to as
• telehealth companies misusing former
telefraud.37 In many cases, the criminals did
employees’ information to order items and
not bill for sham telehealth visits. Instead, the
services.
perpetrators billed fraudulently for other items
or services, like durable medical equipment
Source: HHS OIG analysis of OIG hotline complaints
or genetic tests. In a small number of these
data, 2022.
cases, the sham telehealth visits were billed to
Medicare. In one example, a laboratory owner
paid kickbacks to an individual to arrange for telehealth providers to order genetic testing on behalf
of Medicare beneficiaries.38 This individual then gave Medicare beneficiary information to these
providers, which they could use to bill for telehealth services. In other cases, telehealth company
executives allegedly paid providers to order medically unnecessary durable medical equipment.39
In some instances, the providers allegedly billed Medicare for telehealth services that did not occur.

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Quality of Care and Patient Safety
Little is known about the impact of telehealth on quality of care in Medicare
A recent HHS OIG report indicated the need to evaluate
the impact of telehealth and audio-only services on
quality of care in Medicare.40 Knowing the services and
populations for which telehealth works best is critical
to help stakeholders make decisions about the use of
telehealth and audio-only services in the future. See
Exhibit 6 for one study about the impact of telehealth on
quality of care.41 Additionally, another study of Medicare
fee-for-service beneficiaries found that receiving
telehealth services related to opioid use disorder was
associated with improved treatment retention and
decreased odds of an overdose.42 Other HHS OIG work
found limited information is available on the impact of
telehealth on quality of care in Medicaid.43

Exhibit 6: A recent analysis shed light
on the impact of telehealth on Medicare
hospital readmissions
One study looked at hospital readmission
rates for beneficiaries who received
telehealth services following their hospital
visits. The study had mixed results, showing
that telehealth follow-up visits led to slightly
worse outcomes than in-person follow-up
visits, but far better outcomes than no
follow-up visits.

Additional Data Needed for Oversight
Additional information is needed in Medicare
data to improve oversight of telehealth services

Source: CMS, Cares Act Telehealth Expansion: Trends
in Post-Discharge Follow-Up and Association with 30Day Readmissions for Hospital Readmissions Reduction
Program Health Conditions, January 2022.

Improving the Medicare data is critical to monitoring the program and identifying providers with
concerning billing for telehealth services. These data can also be used to better understand the
use of telehealth and how it may impact quality of care. Recent HHS OIG reports revealed specific
vulnerabilities in the Medicare billing data that are important to the oversight of telehealth services.
First, CMS lacks comprehensive data on audio-only telehealth services. CMS billing data
distinguishes between audio-only and audio-video use for only a limited number of telehealth
services.44 This lack of data inhibits CMS’s ability to identify all telehealth services provided audioonly, as well as its ability to assess the use of audio-only telehealth services and their impact on
quality of care and program integrity.
Second, a Medicare billing practice—known as “incident to” billing—creates challenges for oversight.
This practice 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.
This lack of transparency prevents CMS and oversight agencies from determining which provider
rendered a telehealth service to a beneficiary, which is critical to oversight.45
Third, there is no systematic way to identify telehealth companies in the Medicare data.46 This
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information is important to more closely monitor these companies and to improve oversight of
telehealth services.
Fourth, not all types of Medicare providers are required to report when services are provided
via telehealth. Importantly, opioid treatment programs—which provide treatment for opioid use
disorder—do not submit information about all services that are provided via telehealth.47 This
information is critical to improving the monitoring of telehealth services and to assessing their
impact on the quality of treatment services.

Current Program Integrity Safeguards
To address program integrity risks related to telehealth, CMS uses existing tools such as pre- and
post-payment edits and Fraud Prevention System edits.48 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.49 CMS also conducts
provider interviews, beneficiary interviews, and medical reviews to determine if services billed were
medically necessary. For example, one CMS contractor is currently conducting medical reviews of
Medicare fee-for-service telehealth services and audio-only services that were billed during the
pandemic.50 When appropriate, CMS can also take actions such as payment suspension, revocation
request, overpayment demand, or referral to law enforcement.

NEEDED PROGRAM INTEGRITY SAFEGUARDS
OIG data analyses and the concerns raised in these reports underscore the need for additional
evaluation of the impact of telehealth on quality of care. They also demonstrate the need for
strengthening targeted oversight of telehealth services.
To improve program integrity for Medicare telehealth services, in recent reports the HHS OIG has
recommended that CMS take the following specific actions:

» strengthen monitoring and targeted oversight of telehealth services;
» provide additional education to providers on appropriate billing for
telehealth services;

» improve the transparency of “incident to” services when clinical staff primarily delivered a
telehealth service;

» identify telehealth companies that bill Medicare;
» require a modifier to identify all audio-only telehealth services provided in Medicare; and
» collect data on the use of telehealth in opioid treatment programs.
51

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Department of Defense

TRICARE
The Defense Health Agency (DHA) administers the TRICARE private sector health benefit, which
is part of the DoD’s managed health care program. TRICARE provides health care services to
approximately 9.6 million active duty, retired, National Guard, and Reserve members, their families,
survivors, and qualified beneficiaries.
According to the TRICARE Policy Manual, TRICARE consists of three health care plan options:
TRICARE Prime, TRICARE Select, and TRICARE For Life.52 TRICARE Prime beneficiaries use military
treatment facilities and designated civilian provider networks. TRICARE Select beneficiaries use the
civilian provider network, but they can also use military treatment facilities when space is available.
TRICARE for Life is Medicare wraparound coverage for beneficiaries who have Medicare Parts A and
B.53
TRICARE reimburses providers for telehealth services through a fee-for-service arrangement based
on an allowable charge.54 The allowable charge is the maximum amount TRICARE will authorize for
health services. TRICARE bases the allowable charge on Medicare reimbursement methodologies.
To bill TRICARE, health care providers must meet certain requirements, such as appropriate
licensure and authorization, and deliver medically necessary services.55
Scope of DoD Review: This review describes the types of telehealth services offered through
the DoD TRICARE Program. We focused on TRICARE Prime and TRICARE Select telehealth claims
serviced by two managed support services contractors, which administer the preferred provider
network in the continental United States.56 The DHA defines telehealth as the use of information
and telecommunications technology to provide medically and psychologically necessary and
appropriate diagnostic and treatment services across distances. Our review includes data on
private sector telehealth services from the first year of the COVID-19 pandemic, March 2020–
February 2021, and the prior year, March 2019–February 2020 (see Appendix B for DoD OIG’s
methodology).

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TRICARE TELEHEALTH POLICY CHANGES DURING THE PANDEMIC
Due to the COVID-19 pandemic, in May 2020, the DHA issued an interim final rule to expand
temporary access for TRICARE telehealth services.57 Specifically, the DHA created flexibility for
beneficiaries to use telehealth. For example, the DHA temporarily lifted a requirement that patients
use full audio and video during telehealth appointments, allowing patients to use audio only. The
DHA also waived copayments for telehealth services.58 (See Exhibit 1 for key policy changes during
the pandemic.)
Services: Prior to the COVID-19 pandemic, the TRICARE Operations Manual required providers to
implement telehealth services to the greatest extent practical. The DHA officials reported that there
is not a specific authorized list of services, which providers can deliver through telehealth.
Patients and Providers: During the COVID-19 pandemic, TRICARE beneficiaries could access
telehealth services by using video teleconferencing or audio only (telephone). Prior to the COVID-19
pandemic, TRICARE beneficiaries could receive audio-only telehealth services only under limited
circumstances. The DHA officials also reported that they added TRICARE coverage for remote
monitoring of acute and chronic conditions during the pandemic. Prior to the COVID-19 pandemic,
the DHA did not allow coverage of remote physiologic monitoring for acute and chronic conditions.
The DHA officials reported that they authorized an exception to policy for telehealth capabilities
covering applied behavioral analysis services, such as unlimited use of family adaptive behavior
treatment. Prior to the COVID-19 pandemic, the DHA did not authorize unlimited use of family
adaptive behavior treatment. The DHA issued guidance that authorized temporary telehealth care
support for applied behavior analysis. This guidance applied to parents or caregivers’ services
covering children with autism.
During the COVID-19 pandemic, the DHA authorized reimbursement for interstate practice even if
the provider did not have a license in the state where the patient is located, covering states that
had in-state licensure-waivers as part of their pandemic response. Prior to the COVID-19 pandemic,
TRICARE did not reimburse telehealth service providers who did not have a license in the state
where the patient is located.
Payment Rates: During the COVID-19 pandemic, DHA authorized providers to receive
reimbursement of an equivalent amount as if the providers rendered the service in person. Prior to
the pandemic, providers did not receive reimbursement of an equivalent amount as if the provider
rendered the telehealth service in person.
In May 2020, the DHA waived beneficiary copayments and cost-sharing, including deductibles, for
telehealth services. Prior to the COVID-19 pandemic, beneficiaries were responsible for copayments
and cost-sharing, including deductibles.

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Exhibit 1: Key Differences in TRICARE Telehealth Services Prior to and During the COVID-19
Pandemic

During the Pandemic

Prior to the Pandemic

Patients could receive many
telehealth services using either
audio-video or audio-only.

Under most circumstances,
audio-video was required.

$
+
$ $

Beneficiaries were
responsible for copayments
and cost-sharing
(including deductibles).

The DHA waived beneficiary
obligations for copayments
and cost-sharing
(including deductibles).

TRICARE did not authorize
reimbursement for interstate
practice if the provider did not have
a license in the state where the patient
is located.
The DHA did not authorize providers
to receive reimbursement of an
equivalent amount as if the telehealth
service was rendered in person.

TRICARE authorized
reimbursement for interstate
practice even if the provider did not
have a license in the state where the
patient is located.
The DHA authorized providers

$ $ to receive reimbursement of an
equivalent amount as if the
service was rendered in person.

The DHA did not allow coverage
of remote physiologic monitoring
for acute and chronic conditions.

The DHA added TRICARE coverage
for remote physiologic monitoring
of acute and chronic conditions. Remote
physiologic monitoring includes services
such as weight, blood pressure, and
pulse checks.

The DHA did not authorize
unlimited use of “parent/
caregiver” guidance.

The DHA authorized an exception to policy
for telehealth capabilities covering applied
behavioral analysis services. TRICARE
permitted unlimited use of
“parent/caregiver” guidance
through telehealth services if authorized
by the contractor.

Source: DoD OIG analysis of DHA policy and data requests, 2022.

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TELEHEALTH USE IN TRICARE DURING THE COVID-19 PANDEMIC
During the first year of the COVID-19 pandemic, approximately 1.7 million
TRICARE private sector beneficiaries used telehealth services.
During the first year of the COVID-19 pandemic, from March 2020-February 2021, approximately
1.7 million TRICARE private sector beneficiaries used telehealth services. These beneficiaries
represent 49 percent of the 3.5 million TRICARE private sector participants.

Beneficiaries used 102 times as many telehealth services during the first year of
the COVID-19 pandemic than they did the prior year.
TRICARE private sector beneficiaries used approximately 5.9 million telehealth services during the
first year of the COVID-19 pandemic—102 times more than during the prior year. In total, TRICARE
paid over $394.2 million for telehealth services for private sector beneficiaries, compared with only
$4 million paid the prior year. (See Exhibit 2.)
Exhibit 2: Key Differences in Beneficiary Use of TRICARE Private Sector Telehealth Services
Prior to and During the COVID-19 Pandemic

Prior (March 2019 -- February 2020)

During (March 2020 -- February 2021)

Telehealth services were used
by 23.9 thousand patients

Telehealth services were
used by 1.7 million patients

Patients received
57.5 thousand services
via telehealth

Patients received
5.9 million services
via telehealth

TRICARE paid $4.0 million
for telehealth services for
private sector beneficiaries

TRICARE paid over
$394.2 million
for telehealth services for
private sector beneficiaries

Source: DoD OIG analysis of DHA reported data, 2022.

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Private Sector TRICARE beneficiaries most commonly used telehealth for primary
care, mental health, and specialty care.
According to data provided by the DHA, primary care, mental health, and medical specialty care
service types accounted for 81 percent of all telehealth services during the first year of the
COVID-19 pandemic. Primary care alone accounted for almost half (40 percent) of all telehealth
services during the first year. The “other” category consisted of service types not related to primary
care, mental health, or medical specialty care, and accounted for only 19 percent of the telehealth
services used during the COVID-19 pandemic. (See Exhibit 3 for a comparison of telehealth claims
before and during the pandemic.)
Exhibit 3: Most common telehealth services during the first year of the pandemic and the year
prior

Primary Care

Mental Health

Specialty Care

Other

2,156,085
34,416
1,885,903
12,331
726,088
5,870
1,089,447
4,841
During the Pandemic

Year Prior to the Pandemic

Source: DoD OIG presentation of DHA reported data, 2022.

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PROGRAM INTEGRITY RISKS RELATED TO TELEHEALTH SERVICES
IN TRICARE
The use of telehealth increased substantially during the COVID-19 pandemic and brought changes
to TRICARE’s telehealth policy. Those changes emphasize the importance of determining whether
providers are billing for telehealth services appropriately, identifying ways to safeguard the
program, and ensuring quality of care. This section highlights program integrity risks related to
billing, quality of care, and data, as well as needed safeguards for telehealth services. We focus on
several schemes that providers may be using to inappropriately bill for telehealth services. We also
shed light on potential methods for safeguarding the program and ensuring the quality of care for
beneficiary telehealth services.

Program Integrity Risks Related to
Billing
Data provide insight into potential
fraud schemes.
The DHA developed 12 program integrity
measures to identify providers whose billing
poses a high risk to the TRICARE Program.
Specifically, the DHA Program Integrity
Division developed the measures based on
DHA policy, analysis, and input from TRICARE
managed care support contractors. The
12 measures focus on schemes indicating
possible fraud, waste, or abuse. (See Exhibit
4 for a list of these measures.)
The managed care support contractors
used the measures to identify providers
whose telehealth billing poses a high risk
to TRICARE. From March 2019 through
February 2021, the managed care support
contractors identified only a few providers
whose telehealth billing poses a high risk to
the TRICARE Program. To address the highrisk providers, the managed care support
contractors provided education, recouped
funds, placed providers on prepayment, and
closely monitored a provider.

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Exhibit 4: Program Integrity Measures
To identify telehealth providers whose billing for telehealth
services poses a high risk to TRICARE, the DHA developed
12 measures based on DHA policy, analysis, and input
from TRICARE managed care support contractors:
• Billing duplicate claims
• Billing separate components of a procedure instead of
billing one single code
• Billing for questionable practices
• Billing charges more than the allowable rate
• Billing issues disclosed through provider voluntary
self-reporting
• Billing for any item or service furnished during the
period during which a provider is excluded from
delivering services
• Billing for services inappropriate for telehealth delivery
• Billing telehealth services at the most expensive level
every time
• Billing eight plus hours of telehealth services per day
• Billing applied behavior analysis telehealth services for
hours exceeding an 8-hour day
• Billing of outliers for telehealth modifiers and codes
• Billing both an originating site fee and a distant site
fee for telehealth
Source: DoD OIG presentation of DHA reported data, 2022.

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An audit revealed that the DHA improperly paid telehealth claims.
According to a recent DoD OIG audit report, the DHA improperly paid telehealth claims for FY
2020 telehealth services.59 The DoD OIG reviewed the medical records of 138 beneficiaries and
determined that the DHA improperly paid 107 originating site fee claims.60 The DoD OIG statistically
projected that 69 percent of the FY 2020 originating site fee payments completed by the DHA were
unsupported by adequate documentation in accordance with DHA and TRICARE policy. Specifically,
the DHA improperly paid 67 claims to providers that submitted claims for both originating site
fees and distant site telehealth services.61 In addition, the DHA incorrectly paid 66 originating site
claims where the beneficiary received care outside of medical facilities (for example, at home or in
a car). These improper payments occurred because the DHA did not implement controls to prevent
payment in two different scenarios. First, controls were not adequate to prevent payment when the
same provider billed for the originating site and distant site services. Second, controls were not
adequate to prevent payment of claims when the beneficiary was not present at the originating site.
The DoD OIG also reported that the DHA improperly paid 15 distant site claims that the provider
did not code as telehealth visits in accordance with TRICARE policy. Specifically, the DHA did not
implement controls to reject improperly coded claims. Because of improperly paid telehealth claims,
the DoD OIG projected that the DHA potentially overpaid health care providers for originating site
fees by $620,162 from October 2019 through June 2020.

Quality of Care
Potential quality issues increased during the first year of the pandemic for
TRICARE.
According to the TRICARE Operations Manual, the managed care support contractors are required
to monitor providers using parameters that address quality of care.62 Additionally, contractors are
required to conduct and report quarterly reviews of medical records to determine the quality of care
provided. To emphasize the importance of quality of care and verification of services provided, the
TRICARE Policy Manual established minimum documentation requirements, along with specific
timeframes for incorporating the information into a beneficiary’s medical records.63 For example,
medical records should include the admission evaluation report within 24 hours of admission; a
complete history and physical examination report within 72 hours; nursing notes at the end of each
shift; and daily physical notes.
According to DHA Program Integrity Division officials, the TRICARE East contractor identified seven
potential quality issues related to telehealth before the pandemic (March 2019 to February 2020).
However, that number increased to 89 potential quality issues during the first year of the pandemic
(March 2020 to February 2021) as providers began the transition to telehealth during the COVID-19
pandemic. TRICARE West contractor officials explained that cases related to the quality of care are
not limited to or tracked specifically by telehealth related services. However, the officials stated that
they are unaware of any quality issues specifically concerning telehealth services.
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Additional Data Needed for Oversight
Telehealth-specific data are needed to better understand the use of telehealth
and how it may affect the TRICARE Program.
The DHA lacks the necessary data to distinguish between clinical and telehealth services. Due to
the substantial increase in the use of telehealth during the COVID-19 pandemic, improving TRICARE
data specific to telehealth is critical to monitoring the DoD TRICARE Program and identifying
providers that pose a high risk to the TRICARE Program. Data specific to telehealth can be used to
better understand the use of telehealth and how it may affect the DoD TRICARE Program.
The recent 2020 DHA Program Integrity Division Operational Report identified improvements
required to oversee health care anti-fraud activities to protect benefit dollars and safeguard
beneficiaries.64 According to the 2020 DHA Program Integrity Division Operational Report,
TRICARE’s managed care support contractors reported that calendar year 2020 prepayment
duplicate denials totaled over $450,000. However, DHA Program Integrity Division officials stated
that they cannot determine whether these pre-payment duplicate denials relate to telehealth
services. According to DHA Program Integrity Division officials, the Government only requires the
managed care support contractors to report an aggregate number of prepayment duplicate denials
and not breakdown their data to the specific place of service.
Additionally, the 2020 DHA Program Integrity Division Operational Report states that the DHA
requires contractors to have a pharmacy daily claims audit process. However, the DHA Program
Integrity Division officials stated that they could not determine whether the daily claims audit
process was relevant to telehealth. Furthermore, the DHA Program Integrity Division officials stated
that the daily claims audit does not indicate whether providers performed medical services via
telehealth or in the office.

Current Program Integrity Safeguards Used by the DHA
To address program integrity risks related to telehealth, the DHA uses tools such as pre-payment
edits; post-payment utilization reviews; fraud hotlines; and pre- and post-payment duplicate
screening.65 The DHA also encourages providers to conduct voluntary self-evaluations and make
voluntary disclosures. When appropriate, the DHA can also take actions such as to exclude
or suspend providers from the TRICARE Program. The DHA surveys contractors to determine
what safeguards the contractors have in place to ensure the integrity of the TRICARE telehealth
program. For example, one TRICARE managed care support contractor built some internal oversight
mechanisms, such as data analytics dashboards, to identify providers that billed more than
8 hours of telehealth services in one day and applied behavioral analysis provider hours during
the COVID-19 pandemic. Another TRICARE managed care support contractor established a review
method to prevent inappropriate telehealth reimbursement; created automated system edits to
review or reject claims that do not meet specific criteria; and used fraud detection software to
detect abnormal telehealth usage.
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NEEDED PROGRAM INTEGRITY SAFEGUARDS
To improve program integrity for TRICARE telehealth services, the DoD OIG in a recent report
recommended that the DHA take the following specific actions:

»
»
»
»
» establish controls that prevent payment of services inappropriate to telehealth delivery.

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Office of Personnel Management

Federal Employees
Health Benefits Program
OPM contracts with over 80 health insurance carriers to provide health care benefits to more than
8 million federal employees, eligible family members, and other eligible individuals through the
Federal Employees Health Benefits Program (FEHBP). Contracted FEHBP carriers process and pay
health care claims; provide customer service and access to health care providers and hospitals;
and deliver other health care related services and benefits, including telehealth services.
Scope of OPM Review: This review describes how telehealth services are administered by
10 selected FEHBP carriers. These selected carriers cover a range of carrier sizes and types,
providing services as either an experience-rated fee-for-service carrier,67 an experience-rated
health maintenance organization carrier,68 or a community-rated health maintenance organization
carrier.69 The review also provides data on telehealth services used by members enrolled in one of
our larger FEHBP plans, covering approximately 68 percent of our total enrolled members, between
March 2019 and February 2021. An additional timeframe of March 2021 through December 2021
was reviewed as well, to gain insight into telehealth utilization as the pandemic continued. See
Appendix C for OPM OIG’s methodology.

TELEHEALTH IN THE FEHBP DURING THE COVID-19 PANDEMIC
In response to the COVID-19 pandemic, OPM issued several Carrier Letters70 in 2020 and 2021,
urging carriers to review their preparedness and take necessary steps to provide services for FEHBP
members without interruption. Additionally, carriers were encouraged to consider solutions that
waive cost-sharing, including for health savings accounts71 and qualified high deductible health
plan72 options, for testing and telehealth visits to minimize barriers to testing and treatment for
FEHBP members. OPM strongly encouraged carriers to: focus on mental health, opioid use disorder,
and substance use disorder benefits; leverage telehealth expansion for rural populations and to
address provider shortages; and educate members regarding the availability of these services.
Services: OPM does not specify the types of services that may or may not be offered via telehealth,
but rather leaves this up to the carriers to decide. Therefore, OPM itself did not expand covered
telehealth services in response to the pandemic. However, at OPM’s encouragement and direction
through Carrier Letter 2020-08 and the Call Letter in 2021, most FEHBP carriers reported that they
did expand the services available via telehealth and will continue with the expanded telehealth
services post-pandemic.
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See Exhibit 1 for more information about the telehealth services carriers reported were covered
during the pandemic.
Members and Providers: OPM does not specify the
types of members or the types of providers who may
use telehealth, but rather allows carriers to set their
own policies. During the pandemic, members could
access telehealth services on-demand by telephone or
online video or messaging. This allowed members to
receive telehealth services from any setting, through
access portals73 operated by telehealth companies
such as Teledoc, AmWell, Doctor on Demand, MeMD,
MDLive, or any other local provider’s portal. Telehealth
services could be accessed via a member’s personal
smart phone, tablet, or computer, or through devices
offered in inpatient treatment used to communicate
with providers in a remote setting.
Payment Rates: OPM does not set payment rates for
services or plan allowances, but does negotiate with
carriers to set cost-sharing (including copayments,
coinsurance, or deductibles). OPM also regularly
issues updated guidance to carriers in the form of
carrier letters, encouraging the coverage of various
types of care. In 2020 and 2021, OPM did encourage
carriers to waive cost-sharing for COVID-19 testing and
telehealth visits related to the treatment of COVID-19,
to increase access to treatment and continuity of
care74 during the pandemic. See Exhibit 2 for more
details on these carrier letters.

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Exhibit 1: Examples of telehealth services
that FEHBP carriers reported were covered
during the pandemic:
Office visits (such as a visit with a Primary Care
Physician or specialist)
Preventive (such as an annual wellness visit,
diabetes management, or nutritional services)
Behavioral health (such as individual or group
therapy or psychological testing)
Substance use disorder (such as individual or
group counseling)
Physical, Occupational, and Speech Therapy
(such as a physical therapy assessment)
Cardiac Rehabilitation (such as a visit with a
physician or qualified health care professional,
with or without ECG monitoring)
Cognitive performance (such as performance
testing or therapeutic interventions)
Source: OPM OIG analysis of Claims Data Warehouse
data, 2022.

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Exhibit 2: OPM Carrier Letters Mentioning Telehealth Prior to and During the COVID-19
Pandemic

Prior

During

2016-03: Issued February 2016, OPM encouraged
carriers to offer virtual visits. For more information,
carriers were directed to accreditation standards
issued by the American Telemedicine Association
and Utilization Review Accreditation Commission.

2020-02: Issued March 2020, OPM stated that
encouraging members to use telehealth services
would help limit the spread of COVID-19. Encouraged
carriers to consider waiving cost sharing for testing
and telehealth visits related to COVID-19.

2017-01: Issued January 2017, OPM encouraged
carriers to leverage telehealth and to describe the
areas in which telehealth would be implemented or
expanded in 2018. The letter especially highlighted
cost savings and telehealth behavioral health
services.

2020-08: Issued April 2020, OPM stated that carriers
who had not already done so should strongly consider
waiving cost-sharing for telehealth services associated
with the treatment of COVID-19. Clarified coverage for
specific plan types related to the safe harbor section
of the CARES Act.

2019-01: Issued January 2019, OPM encouraged
carriers to consider leveraging telehealth services
to address provider shortages and substance use
disorder. Also encouraged carriers to educate
members regarding the availability of these services.

2021-03: Issued February 2021, OPM stated that it
and the carriers have worked and will continue to work
together to ensure all FEHBP enrollees have equitable
access to diagnostic tests, therapeutics, vaccines,
and telehealth coverage. Carriers should leverage
ongoing telehealth expansion and member education
regarding the availability of telehealth services to
address mental health provider shortages.

2019-05: Issued April 2019, OPM strongly encouraged
carriers who offered a telehealth benefit to provide
OPM information regarding how telehealth was being
used in mental health coverage and substance use
disorder services.

2021-05: Issued April 2021, FEHBP carriers were
asked to describe their efforts at ensuring members
have equitable access to telehealth coverage related
to COVID-19. OPM reiterated the message from carrier
letter 2021-03 (see above). OPM encouraged carriers
to expand telehealth to address rural populations that
lack adequate providers for substance use disorder
treatment services. Also, OPM encouraged the delivery
of coordinated care leveraging telehealth technologies.

2020-01: Issued January 2020, OPM reiterated
assessing telehealth services for substance use
disorder treatments.

Source: OPM Website, Healthcare and Insurance, https://www.opm.gov/healthcare-insurance/healthcare/carriers/#url=CarrierLetters

Carriers reported a variety of responses to the suggestion to waive cost-sharing for testing and
telehealth visits related to the treatment of COVID-19; most waived members’ copayments and
coinsurance for at least a portion of 2020/2021 for either all telehealth services or for only those
services that led to a COVID-19 diagnosis. However, many of the 10 carriers selected for this review
indicated that they have already restored or plan to restore member cost-sharing responsibilities
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for telehealth services moving forward. We did note that the member cost-sharing responsibility
was most frequently waived when a carrier-contracted telehealth company’s portal was used.
Contrastingly, members usually paid a higher copayment when utilizing their local providers’
telehealth portals.

During the first year of the pandemic, the number of unique FEHBP members who
used telehealth services increased by 2,733 percent compared to the prior year.
From March 2020 through February
2021, a total of 2.2 million unique
FEHBP members from one of
our larger FEHBP carriers used
a telehealth service. These 2.2
million members represented 40
percent of the 5.6 million members
enrolled under this carrier, or
about 4 in 10 members. This is a
dramatic increase from the prior
year, when just 1 percent—78,900
in total—of this same FEHBP
carrier’s members used telehealth
services.

Exhibit 3: Ratio of Members using Telehealth Prior
to and During the COVID-19 Pandemic

1% of
members

used telehealth

Pandemic Response Accountability Committee

during the
pandemic

Source: OPM OIG analysis of Claims Data Warehouse data, 2022.

In total, this same FEHBP carrier’s
members filed over 8 million claims for
telehealth services during the pandemic
period of March 2020 through February
2021. This amounts to over 54 times
more telehealth service claims than
the 148,035 filed in the prior year. This
FEHBP carrier also paid over $646
million for telehealth services during this
same period, which is a 6,259 percent
increase—over 63 times more—from the
year prior, when only $10,164,062 was
paid for telehealth claims.

DoD

used telehealth

prior to
pandemic

Telehealth claims increased by
5,335 percent during the pandemic
compared to the prior year.

HHS

40% of
members

OPM

Exhibit 4: Number of Telehealth Claims Prior
to and During the COVID-19 Pandemic
8,045,165

148,035
Year Prior to the
Pandemic

During the
Pandemic

Source: OPM OIG analysis of Claims Data Warehouse data, 2022.
Note: Data analysis was based on claims data from one carrier,
covering approximately 68 percent of enrolled members.

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FEHBP members most commonly used telehealth for office visits and behavioral
health services.
For the FEHBP carrier we analyzed, these two service types together accounted for over 91 percent
of all telehealth services during the first year of the pandemic. Office visits—routine appointments
with primary care providers or specialists—accounted for 58 percent of all telehealth services. In
addition, behavioral health services accounted for 33 percent of all services. Behavioral health
services include individual therapy, group therapy, and substance use disorder treatment, among
others. This carrier’s members also utilized telehealth for physical, occupational, and speech
therapies as the third most utilized health care service, although this accounted for just four
percent of overall telehealth services. The data from this carrier shows that the trend of members
using telehealth for all of these services continued through the end of 2021.
Exhibit 5: Total Claims for Key FEHBP Telehealth Service Categories During the COVID-19
Pandemic
5,364,648

Office/Outpatient Services

3,086,693

Behavioral Health

375,953

PT, OT, and Speech Therapies
Care Management/Coordination
Home Services

27,766
8,731

Source: OPM OIG analysis of Claims Data Warehouse data, 2022.
Note: Data analysis was based on claims data from one carrier, covering approximately 68 percent of enrolled members.

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Exhibit 6: Key Differences in Member Use of FEHBP Telehealth Services Prior to and During the
COVID-19 Pandemic

Prior

(March 2019 -- February 2020)

During

(March 2020 -- February 2021)

1% of members
used telehealth
services

40% of members
used telehealth services

Members received
8 million services
via telehealth

Members received
148 thousand
services via
telehealth
Only 2% of all
telehealth services
for our scope (March
2019 – December 2021)
were incurred in the year
prior to onset of COVID-19
Members most commonly
used telehealth for counseling,
psychiatric care, and internal
medicine service types.

Extended COVID

(March 2021 -- December 2021)
24% of members
used telehealth services

Members received
5 million services
via telehealth

61% of telehealth
services incurred
during our scope
were received after
the onset of COVID-19
Members most commonly
used telehealth for counseling
and psychiatric care, internal
medicine, and family practice
service types.

37% of telehealth
services incurred during
our scope were received
throughout the remaining
10 months of 2021
Members most commonly used
telehealth for counseling and
psychiatric care, internal medicine,
and family practice service types.

Source: OPM OIG analysis of Claims Data Warehouse data, 2022.

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Exhibit 7: Most telehealth services were obtained via a member’s local provider portal, as
opposed to a carrier-contracted portal
For the 10 surveyed carriers, FEHBP members can access telehealth services either via their health
insurance carrier’s contracted telehealth company’s portal or via their local preferred provider’s
portal. However, claims data for the carrier we analyzed showed that most members received
telehealth services from the local preferred provider.
In fact, during our analysis of the claims data, we found that only three percent of telehealth claims
incurred during the scope of this review came from the carrier’s contracted telehealth company’s
portal. We found this particularly interesting because cost-sharing for members is typically waived
when the carrier’s contracted telehealth company’s portal is used, but is not waived when a
member chooses to use their local provider’s portal.* There are several factors that may have
contributed to the high ratio of members utilizing their preferred provider’s portals. First, this
could suggest that members are willing to pay a small premium in order to obtain services from
physicians with whom they may have an established relationship. On the other hand, it could be
that not all members were aware of the free telehealth portals available to them. It is also possible
that limitations on services available via a carrier’s contracted telehealth company’s portal could
have required members to see their local providers for some services. Further work would be
needed to determine what influenced members’ decisions as to which type of telehealth visit to
utilize.
*Note: This distinction does not apply to services related to testing and/or treatment of COVID-19,
which requires no copayment, regardless of telehealth portal.
Source: OPM OIG analysis of Claims Data Warehouse data, 2022.
Note: Data analysis was based on claims data from one carrier, covering approximately 68 percent of enrolled members.

PROGRAM INTEGRITY RISKS RELATED TO TELEHEALTH SERVICES IN
THE FEHBP
The dramatic increase in the use of telehealth services since the beginning of the COVID-19
pandemic and the lack of centralized policies for telehealth in the FEHBP underscores the
importance of determining whether providers are billing for telehealth services appropriately and of
identifying ways to safeguard the program and ensure quality of care.
This section highlights program integrity risks related to billing and quality of care, as well as
needed safeguards for telehealth services.75 We focus on several schemes that providers may
be using to inappropriately bill for telehealth services and shed light on potential methods for
safeguarding the FEHBP and protecting members’ safety specific to telehealth.

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Program Integrity Risks Related to Billing
Data analyses provide insight into billing schemes and identify providers whose
billing poses a high risk to the FEHBP.
The OPM OIG’s analyses of FEHBP telehealth services
claims data shed light on a number of schemes
that providers may use to inappropriately maximize
their FEHBP payments for telehealth services. We
developed six measures that focus on different
schemes to identify providers whose billing may
indicate fraud, waste, and abuse.76 See Exhibit 8 for a
list of these measures.
Using these measures, we identified over 560
providers whose telehealth billing poses a high risk
to the FEHBP. While these providers represent a
small proportion of the approximately 265,00077
providers who billed for a telehealth service between
March 2019 and December 2021, their billing raises
concern. For example, some providers billed office visit
telehealth services at the highest, most complex level
every time. In these cases, providers may be delivering
higher levels of services than medically necessary or
billing for levels of services that were not rendered—a
scheme that is sometimes called “upcoding.” In other
cases, providers billed for telehealth services for a high
number of days in a year. Billing in this manner may
indicate that the provider is billing for services that
were not provided.

Exhibit 8: Program Integrity Measures
To identify telehealth providers whose billing
for telehealth services poses a high risk to the
FEHBP, OPM OIG developed six measures to
analyze:
• Billing telehealth services at the highest,
most expensive level every time
• Billing telehealth services for a high number
of days in a year
• Billing a high average number of hours of
telehealth services per visit
• Billing telehealth services for a high number
of members
• Billing for telehealth services unrelated to
the providers’ specialty
• Preferred providers billing high percentages
of patients at long distances
Source: OPM OIG analysis of Claims Data Warehouse
data, 2022.

Quality of Care and Patient Safety
Little is known about the impact of telehealth on quality of care in the FEHBP.
Knowing which services and which populations telehealth works best for is critical to help
stakeholders make decisions about the use of telehealth services in the future. OPM has
specifically recommended expansion of telehealth services to combat the opioid epidemic, mental
health provider shortages, and continuity-of-care issues during the COVID-19 pandemic.78 However,
little is known about the effects of telehealth expansion in these areas on quality of care received,
patient safety, or FEHBP member outcomes. OPM’s Healthcare and Insurance (HI) does conduct
a Plan Performance Assessment annually, which examines quality of care through clinical quality
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measures. However, this assessment does not include any telehealth-specific measures. Given
the drastic increase in the usage of telehealth services since the onset of COVID-19, we believe
that OPM should evaluate whether the annual Plan Performance Assessment currently includes
measures that would adequately identify quality of care concerns specific to the telehealth modality.
In addition to oversight by OPM itself, FEHBP carriers should also evaluate telehealth quality of care
concerns. In response to our telehealth survey, one carrier indicated that it has a quality plan, which
includes performing random audits, diagnosis trending, and utilization monitoring for claims coming
in through its contracted telehealth company’s portal. However, as discussed above, 97 percent of
telehealth services for this carrier were not obtained through this portal. Further, most carriers we
surveyed indicated only that quality of care concerns will be reviewed when identified via member
grievances. The OPM OIG is not aware of any large-scale reviews specifically examining telehealth’s
effects on quality of care performed by carriers, though this question was not explicitly posed in our
survey.

Current Program Integrity Landscape in the FEHBP
Currently, each participating FEHBP carrier is responsible for administering its own telehealth
benefits, including implementing appropriate integrity safeguards.79 OPM does not place programwide restrictions on the types of services eligible to be performed via telehealth, nor does it
prescribe any required system edits, audits, or reviews to be performed on telehealth claims.
Further, OPM does not set policy on telehealth service coverage or billing practices within the
FEHBP. For example, the responses to our telehealth survey indicated that many carriers waive costsharing for services obtained via the telehealth company with which they have a contract, but not
for telehealth services obtained via local provider portals. Also, while carriers do typically have edits
in place for duplicate payment identification, medical necessity reviews, upcoding, and coordination
of benefits,80 the results of our telehealth carrier survey revealed that some carriers have waived
some or all of these edits for telehealth claims. Further, most carriers we surveyed do not have edits
in place to check for impossible days81 for telehealth providers. Most carriers who responded to our
telehealth survey did indicate that they perform provider education on telehealth billing. In addition,
the OPM OIG does maintain a health care fraud hotline that FEHBP members can contact if they
have concerns about care they received or a suspicious billing practice.
In general, we found that most FEHBP carriers we surveyed have somewhat comprehensive
policies and procedures in place for oversight of carrier-contracted telehealth company’s portals.
However, as mentioned above, services obtained through these portals account for a very small
percentage of FEHBP telehealth claims. A much greater portion of telehealth services are acquired
through a member’s local, preferred provider.82 Our review found that oversight of telehealth in
these situations was extremely limited. Providers may use essentially any technology they desire to
perform their telehealth services, frequently with little, if any, education, or oversight. In response
to our survey questions, many carriers indicated that the providers must follow applicable laws

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and regulations. However, the carriers did not list which regulations applied nor did they indicate
that any oversight was performed to determine whether providers are actually abiding by relevant
requirements.
Finally, OPM has so far left all guidance on telehealth up to the carriers to issue. However, several
of the carriers we surveyed indicated that they do not educate providers on telehealth privacy
concerns and most carriers indicated they have no requirements regarding recording of telehealth
sessions, even to obtain the members’ consent before doing so. Currently, it seems the onus is
largely on FEHBP members themselves to identify suspicious billing practices, privacy and security
concerns, or quality of care issues and report these to their carrier or to the OPM OIG fraud, waste,
and abuse hotline.83 OPM has thus-far maintained a relatively hands-off approach to telehealth
benefit application and oversight in the FEHBP. This, in combination with the effects of the
unprecedented circumstances of the COVID-19 pandemic, has led to greatly varied approaches to
telehealth by various carriers.

PROGRAM INTEGRITY SUGGESTED SAFEGUARDS
The OPM OIG’s analyses have raised concerns regarding
FEHBP program integrity as it relates to telehealth. In
this section, we will lay out these concerns and suggest
actions OPM could take to alleviate them and strengthen
oversight of telehealth in the program.

Key Suggested Safeguards Related to
Carrier Policies:
OPM should develop and maintain a list of
services for which FEHBP providers may be
reimbursed when performed via telehealth
and require carriers to place edits in their
claims systems which will check telehealth
claims against this list.

First, while analyzing the current program integrity
measures described above, we also noticed a pattern
of claims submitted with a telehealth modifier or place
of service which seemingly could not physically be
performed via telehealth. For example, one provider
submitted a claim for procedure code 00830 –
anesthesia for hernia repairs in lower abdomen. Another
included procedure code 11000 – debridement of
extensive eczematous or infected skin. While further
analysis is needed on these types of claims, their
occurrence raises concerns regarding the lack of
restrictions or review placed on telehealth claims in the
FEHBP in general. We believe OPM should develop and
maintain a list of services for which FEHBP providers
may be reimbursed when performed via telehealth and
require carriers to place edits in their claims systems
which will check telehealth claims against this list. OPM
could start with the list maintained by CMS,84 expanding
the allowed services if desired.
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» OPM should consider implementing

telehealth portal requirements, to protect
the privacy of FEHBP members, as well
as to reduce the likelihood of technical
problems around the availability of these
services when needed.

» OPM should specify the telehealth

laws and regulations with which FEHBP
providers must comply and require FEHBP
carriers to ensure providers are doing so.

» OPM should issue guidance to FEHBP
members on telehealth privacy and
security awareness.

Source: OPM OIG analysis of Claims Data
Warehouse data, 2022.

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As discussed above, carriers indicated that FEHBP providers must follow applicable laws and
regulations but did not indicate that any oversight was performed to determine whether providers
are abiding by relevant requirements. Therefore, we believe there are safeguards OPM should
implement in this area. First, while OPM has pointed carriers towards telemedicine accreditation
standards published by the American Telemedicine Association and URAC,85 OPM has not issued
any actual requirements for telehealth portal acceptability. Due to the wide variety of, and in many
cases lack of, security and privacy controls around preferred provider telehealth portals, we urge
OPM to consider implementing telehealth portal requirements, to protect the privacy of FEHBP
members, as well as to reduce the likelihood of technical problems around the availability of these
services when needed. In addition, OPM should specify the telehealth laws and regulations with
which FEHBP providers must comply and require FEHBP carriers to ensure providers are doing so.
As stated above, it seems the onus is largely on FEHBP members themselves to identify suspicious
billing practices, privacy and security concerns, or quality of care issues and report these to their
carrier or to the OPM OIG fraud, waste, and abuse hotline. Therefore, we believe OPM should issue
guidance to FEHBP members on telehealth-related concerns. For example, OPM could encourage
members to review their explanation of benefits documents in detail after each visit to ensure they
were billed only for the services they received. Members could also be encouraged to be aware of a
provider’s surroundings, such as ensuring the provider is in a private location before beginning the
session. In addition to issuing guidance to members, we believe OPM HI should review its annual
Plan Performance Assessment to determine whether the current measures included adequately
address telehealth-specific quality of care concerns.
We believe there is a great need for strengthening effective, targeted oversight of telehealth
services in the FEHBP. While OPM has maintained a relatively hands-off approach to telehealth
benefit application and oversight, the COVID-19 pandemic has highlighted potentially detrimental
gaps in the varied approaches to telehealth by various carriers. We believe centralized guidance
that applies to all FEHBP carriers and providers would significantly increase FEHBP member safety
and protect the integrity of the FEHBP overall.

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Department of Veterans Affairs

Veterans Health
Administration
The VA runs the largest integrated health care network in the United States. According to VA,
as of March 2020 over 9 million veterans were enrolled in VA health care with over 5.6 million
active users.86 VA’s medical benefits package provides comprehensive health services, including
telehealth, to veterans who are enrolled in VA’s health care program.87
VA piloted telehealth care as early as the 1960s. In subsequent decades, VA telehealth grew from
efforts localized at VA facilities to a national program.88 In the early 2000s, VA formally established
telehealth services within the Office of Patient Care Services to improve quality, convenience, and
access to care using telehealth technology.89 VA also developed clinical video telehealth, which
allowed VA providers to diagnose and often treat veterans in real time via interactive, live video. In
2016, VA established the Office of Connected Care to administer telehealth programs throughout
VA. In 2017, VA launched its VA Video Connect (VVC) mobile app to provide a secure environment
for patients and providers to carry out video telehealth visits, regardless of where the veteran and
provider were located. Clinical video telehealth and VVC allow providers to use videoconferencing to
assess, treat, and provide care to veterans remotely. VA clinicians also provide telehealth care via
telephone.
In 2018, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks
(MISSION) Act authorized providers employed by VA to deliver telehealth across state lines,
regardless of where the patient or provider were located or in which state the provider was
licensed.90 The MISSION Act also established the Veterans Community Care Program. Through
this program, VA pays for care, including telehealth, provided by community providers in networks
managed by third-party administrators (TPAs) under certain conditions, including when care cannot
be delivered to veterans by VA providers at VA medical facilities. TPAs pay non-VA providers within
the network they manage for claims and then submit invoices directly to VA for reimbursement.
VA’s cost for community care was about $16.9 billion in fiscal year 2020.91 According to VA, about
2.1 million unique veterans used community care in fiscal year 2020.
Scope of VA OIG Review: This review describes outpatient synchronous telehealth services
between VA providers and enrolled veterans, and between enrolled veterans and non-VA providers
in the community.92 For our analysis of telehealth services provided by VA providers, we included
video and telephone encounters. The types of services included primary care, behavioral health
care, medical and surgical specialty care, and ancillary services.93 The time frames of our review
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of telehealth services provided by VA providers are the year before the COVID-19 pandemic,
March 2019 through February 2020, and the first year of the COVID-19 pandemic,
March 2020 through February 2021.
For our analysis of telehealth services provided by non-VA community providers to veterans, we
analyzed data from VA claims processing systems for paid community care telehealth claims from
March 1, 2019, through December 31, 2021.94 We extended the scope of our review of community
care telehealth claims beyond the first year of the pandemic to also include March 2021 to
December 2021 due to the ongoing nature of the pandemic.

VA TELEHEALTH CHANGES AND USE DURING THE PANDEMIC
Beginning in March and April of 2020, VA took actions to expand telehealth services provided by VA
facilities to ensure that veterans maintained access to health care and to improve veterans’ access
to technology during the COVID-19 public health emergency. These actions included, but were not
limited to, the following:
• March 17: A VA memo to network and facility leaders provided guidance to expedite
credentialing and privileging of health care providers in anticipation of staffing shortages.
• March 19: VA authorized VHA clinicians to use any third-party audio or video communication
technology with privacy features for telehealth appointments.
• March 22: A VA memo advised that veterans with non-urgent appointments who were
concerned about exposure to COVID-19 could access health care via telephone appointments
or telehealth or have the option to postpone and reschedule.
• March 23: VA’s Office of Emergency Management COVID-19 response plan included that VA
would provide most outpatient care for veterans through telehealth.
• April 27: VHA issued a new directive allowing VA employed health care professionals to provide
telehealth services through any VA facility without re-credentialing and re-privileging at each
facility. The purpose of the directive was to facilitate sharing of clinical resources and improve
flexible utilization of health care professional services.95
• March 11, 2021: The American Rescue Plan signed into law allowed VA to reimburse veterans
or waive copayments or other cost sharing for care provided from April 6, 2020, through
September 30, 2021.

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TELEHEALTH USE IN VA DURING THE PANDEMIC
During the first year of the pandemic, almost 4.8 million veterans had a telehealth encounter. This
accounted for 87 percent of the veterans who used VA health care that year and almost twice the
number of veterans who used telehealth the previous year. (Exhibit 1.)
Exhibit 1: Patient Health Care Encounters
March 2019–
February 2020

March 2020–
February 2021

Patients with any health care encounter

5,742,419

5,510,188

Patients with a telehealth encounter

2,334,601

4,794,928

41%

87%

Percent of patients with a telehealth encounter
Source: VA OIG analysis of data from VHA Corporate Data Warehouse.96
Note: Percentages are rounded.

The number of video telehealth encounters increased 181 percent in the first year of the pandemic,
and telephone encounters increased by 211 percent. (Exhibit 2.)
Exhibit 2: Video and Telephone Telehealth Encounters
March 2019–
February 2020

March 2020–
February 2021

Change

Video encounters

2,187,311

6,137,947

181%

Telephone encounters

6,731,555

20,958,287

211%

Source: VA OIG analysis of data from VHA Corporate Data Warehouse.
Note: Percentages are rounded.

Primary care and behavioral health saw large increases in the number of telephone and video
telehealth encounters. Specialty Care and other ancillary services also saw significant increases.
(Exhibit 3.)

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Exhibit 3: Telehealth Encounters by Service Type
March 2019–
February 2020

March 2020–
February 2021

Change

259,246

1,361,288

425%

1,338,719

3,199,457

139%

Specialty Care

408,546

940,141

130%

Other Ancillary Services

180,800

637,061

252%

Primary Care

3,737,064

11,928,965

219%

Behavioral Health Care

1,031,250

5,290,174

413%

Specialty Care

1,861,506

3,381,882

82%

101,735

357,266

251%

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Video
Primary Care
Behavioral Health Care

Telephone

Other Ancillary Services
Source: VA OIG analysis of data from VHA Corporate Data Warehouse.
Note: Percentages are rounded.

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COMMUNITY CARE AND TELEHEALTH
VA uses the Plexis Claims Manager (Plexis) and the Community Care Reimbursement System
(CCRS) to process claims from community care network TPAs. At the time of the pandemic, the TPAs
reported that conducting telehealth must be consistent with Medicare guidelines.

VA Expanded Community Provider Telehealth During the COVID-19 Pandemic
The Centers for Medicare & Medicaid Services (CMS) implemented flexibilities in response to the
pandemic that helped Medicare beneficiaries, including veterans receiving care from community
providers, gain access to more telehealth services without having to go to a medical facility.97 For
example, in March 2020, CMS waived requirements for providers who were previously ineligible for
Medicare telehealth services, including physical therapists, occupational therapists, and speech
language pathologists. Waiving the requirements allowed non-VA providers to provide care and
receive payments for these services.98
Through analyses of claims from non-VA community providers for care that was provided to veterans
via telehealth, the impact on the volume of telehealth usage is clear. The scope of this review
begins one year before the pandemic, the first full year of the pandemic, and then an additional ten
months thereafter to the end of December 2021, reflecting the ongoing nature of the pandemic.

Care Provided to Veterans in the Community via Telehealth: Before and During the
COVID-19 Pandemic
In the 12 months before the pandemic (March 2019 through February 2020), less than one
percent of veterans who received care in the community did so at least once via telehealth. From
March 2020 through February 2021, however, about 19 percent of the 871,000 veterans who
received care in the community did so at least sometimes via telehealth. Fewer veterans received
at least some telehealth care in the community from March 2021 through December 2021—only
8 percent of about 1.1 million veterans.99
Exhibit 4: Percentage of Veterans Using Telehealth in the Community
March 2019 - February 2020

0.5%

19%

March 2020 - February 2021

March 2021 - December 2021

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
Note: Percentages are rounded.

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Exhibit 5 details what VA paid for all community telehealth services prior to the pandemic and
during it. In total, VA spent about $101.8 million on approximately 830,000 community care
telehealth claims for about 215,000 veterans between March 2019 and December 2021.100
Exhibit 5: Growth of Community Telehealth Claims Prior to and During the Pandemic
March 2019–
February 2020

March 2020–
February 2021

March 2021–
December 2021

Number of claims paid

27,500

537,000

267,000

Amount paid (millions)

$3.4

$62.0

$36.5

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
Note: Numbers are rounded.

VA most frequently paid for community behavioral health services that were provided using
telehealth.101 This category of care accounted for about 59 percent of the claims submitted from
March 2019 through December 2021 and represented about $65.2 million in costs. In this
category, the most commonly paid service was psychiatry care. This care also accounted for the
most claims paid during each of the time periods we reviewed.
The next most common type of community telehealth claim from March 2019 through
December 2021—office visits—represented about 243,000 claims. VA paid about $21 million
for the category of “evaluation and management, office visit-established care” during this time
period. Slightly over half of unique veterans (118,000 of about 215,000) who received care in the
community via telehealth received these kinds of visits. This care also accounted for the secondmost claims paid during each of the time periods we reviewed.
Veterans’ use of telehealth during our period of review increased, regardless of whether care was
provided in VA or by community providers. Veterans received care from both VA and community
providers and continued to do so via telehealth when the COVID-19 pandemic limited in-person
care. In fact, VA had been making investments into its in-house telehealth program prior to the
pandemic.

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PROGRAM INTEGRITY RISKS ASSOCIATED WITH TELEHEALTH IN VA
The dramatic changes that came from expanding veteran community care via telehealth during the
pandemic exposed VA to several program integrity risks, including whether VA was being charged
the right amount for care provided to veterans by non-VA providers in the community via telehealth.
We also identified risks for VA’s program that lends veterans devices for video care.

Quality of Care and Patient Safety
Oversight of quality and patient safety processes are necessary to ensure that patients receive
safe and effective health care. For care furnished by VA providers, mandatory credentialing and
monitoring of care ensures that health care providers in occupations that require maintaining
state licensure, certification, and monitoring of time limited credentials are consistently evaluated
on employment and every two years as required.102 This requirement does not apply to health
care providers furnishing health care, including telehealth care, in the community. The MISSION
Act requires non-VA community providers meet certain eligibility requirements, such as having
an unrestricted state license to practice, eligibility to participate in federally funded health care
programs like Medicare and Medicaid, and other credentialing standards. Providers who were
suspended or removed from VA employment for quality of care concerns must be excluded from the
community care network. The credentialing of community providers is conducted by VA’s contractors
and is outside the scope of this review.
Ongoing studies are necessary to further evaluate the effect of telehealth on quality of care during
the COVID-19 pandemic. These studies could evaluate appropriateness of care, readmission rates,
delay in diagnoses, patient satisfaction, barriers to care, and standardized quality metrics and
guidelines.

Program Integrity Risks Related to Community Care Telehealth Claims
Increased community care telehealth claims put VA at risk of fraud and of making inaccurate
payments. Fraud schemes can include, for example, a provider billing for telehealth appointments
occurring at the same time or with multiple veterans located in multiple locations that providers
could not possibly reach during the time frame.103 From March 2019 through December 2021, we
identified about $22.3 million of $101.8 million unique community care telehealth claim payments
(about 22 percent) in four areas that may have exposed VA to increased risk, and some of the
payments exhibited multiple risks.104 We did not review detailed provider information and veterans’
health records to determine whether these claims were valid.105 If VA can identify improper
payments or ones made in error, the payments can be addressed. In the sections that follow on the
risks that telehealth poses to VA’s community care program, our narrative focuses on the first year
of the pandemic (March 2020 through February 2021) to allow readers to readily compare VA’s
risks with those of other federal agencies discussed in this report. However, our data tables include
an additional ten months of data (March 2021 through December 2021) to reflect the ongoing
nature of the pandemic.
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Ineligible Services
From March 2020 through February 2021, VA spent about $62 million on community care via
telehealth claims, of which about $2 million (or about 3.2 percent of spending) were for ineligible
telehealth services. For example, during this period, claims for the fitting, orientation, and
checking—as well as the repair and modification—of hearing aids were not included in the schedule
of telehealth services. VHA spent about $671,000 on these services. Exhibit 6 provides a summary
of the community telehealth claims we identified that were paid for ineligible services.
Exhibit 6: Ineligible Telehealth Services by Veterans, Claims, and Amounts Paid
March 2019–
February 2020

March 2020–
February 2021

March 2021–
December 2021

Veterans with one or more ineligible claim

290 of 6,100
(4.8%)

3,500 of
164,000 (2.2%)

2,400 of 81,600
(3.0%)

Number of ineligible claims

360 of 27,500
(1.3%)

6,700 of
537,000 (1.2%)

6,500 of
267,000 (2.5%)

Amount paid for ineligible claims

$88,700 of
$3.4 mil (2.6%)

$2.0 mil of
$62.0 mil (3.2%)

$1.8 mil of
$36.5 mil (5.0%)

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
Note: Numbers and percentages are rounded.

High-Usage Days
We consider a high-usage day to be when a community care provider billed for a significant
number of hours in a single day. High-usage days could reflect fraudulent billing activities or
could reflect legitimate billing. For this analysis, we define a high-usage day as one in which a
community provider billed for more than 18 hours of telehealth services. From March 2020 through
February 2021, VA paid approximately $578,000 (or less than 1 percent of spending) for
3,400 claims that were associated with high-usage days, as summarized in Exhibit 7.

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Exhibit 7: Summary of Potentially Invalid Community Telehealth Billing for 18 Hours or More in a
Single Day
March 2019–
February 2020

March 2020–
February 2021

March 2021–
December 2021

Number of claims

66 of 27,500
(0.2%)

3,400 of
537,000 (0.6%)

1,100 of 267,000
(0.4%)

Number of providers

15 of 1,900
(0.8%)

56 of 60,400
(0.1%)

13 of 29,100
(0.0%)

$7,100 of $3.4
mil (0.2%)

$578,000 of
$62.0 mil (0.9%)

$191,000 of
$36.5 mil (0.5%)

Amount paid

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
Note: Numbers and percentages are rounded.

High-Intensity Evaluation and Management Claims
Evaluation and management services include assessing a patient’s history or examining a patient
to make a medical decision. For this analysis, we selected claims for community care telehealth
associated with evaluation and management codes. These claims were also reimbursed at higher
levels than other evaluation and management claims. In particular, we defined high-intensity
evaluation and management as claims that require a moderate to high level of decision making
because of their complexity. To identify potential risks, we identified community providers who
were billing VA with at least one high-intensity evaluation and management claim during the review
period. From March 2020 through February 2021, VA’s health care program paid approximately
$10.7 million (about 17 percent of spending) to about 23,400 community providers for about
100,000 high-intensity evaluation and management claims.106

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Exhibit 8: Summary of High-Intensity Evaluation and Management Community Telehealth Claims
March 2019–
February 2020

March 2020–
February 2021

March 2021–
December 2021

Number of claims

4,300 of 27,500
(16%)

100,000 of
537,000 (19%)

40,700 of
267,000 (15%)

Number of providers

520 of 1,900
(27%)

23,400 of 60,400
(39%)

10,900 of
29,100 (38%)

$510,000 of $3.4
mil (15%)

$10.7 mil of $62.0
mil (17%)

$5.1 mil of
$36.5 mil (14%)

Amount paid

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
Note: Numbers and percentages are rounded.

Duplicate Claims
We considered a telehealth claim to be a potential duplicate if it was paid for the same veteran,
community provider, date of service, and current procedural terminology (CPT) code as at least one
other claim. Telehealth duplicate claims were classified by their existence within a single claims
processing system, Plexis or CCRS, or within both systems. Community providers also submitted
potentially duplicate claims for services provided both as telehealth and in-person.
From March 2020 through February 2021, VA paid approximately $1.5 million for about
14,000 possible duplicate telehealth claims involving about 1,900 community providers. These
claims represented about 2.4 percent of total spending on community care telehealth claims.
Exhibit 9 provides additional details on the duplicate claims we identified.
Exhibit 9: Summary of Potentially Duplicate Claims
March 2019–
February 2020
Number of claims

Amount paid

March 2020–
February 2021

March 2021–
December 2021

400 of 27,500
(1.5%)

14,000 of 537,000
(2.6%)

670 of 267,000
(0.2%)

$35,400 of $3.4
mil (1.0%)

$1.5 mil of $62.0
mil (2.4%)

$119,000 of
$36.5 mil (0.3%)

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
Note: Numbers and percentages are rounded.

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Community Care Telehealth Claims Processing Has Limited Controls
Neither Plexis nor CCRS has a system in place to identify claims associated with ineligible services,
potential high-usage days, or high-intensity evaluation and management services for community
care telehealth. A senior VA official reported that VA’s post-payment review processes are not
designed to identify these types of risks. However, the TPAs provide VA quarterly reports that may
include information on claims that may be suspicious.107 A VA official familiar with claims processing
compliance reported that TPA personnel should notify VA of any suspicious provider activity, but TPA
personnel have not discussed the risks identified in this summary with VA.
Regarding duplicate claims, there are processes in place in Plexis and CCRS to reject or deny such
claims. In addition, VA’s Program Integrity Tools generate a report that identifies potential duplicates
between Plexis and CCRS. VA personnel research these claims and coordinate with the TPAs to
determine whether the payments are valid.

Review Revealed Opportunities to Improve VA’s Digital Divide Program
In August 2020, VA’s Office of Connected Care recognized the growing demand for patient access
to video-based virtual care, and that many patients lack a video-capable device or the internet
connection required to access this care.108 To help these individuals, VA introduced the digital divide
consult, where patients are lent a video-capable device after obtaining a referral from their care
team, licensed independent practitioner, or designee, and the approval of a social worker who has
conducted a socioeconomic assessment.109 The digital divide consult improved on a 2016 device
lending process by introducing the social worker assessment to help identify and resolve other
needs and barriers to care.
We found that the VA’s digital divide program was successful in distributing devices to patients,
but identified several gaps in oversight and guidance preventing the program from fully meeting its
intended purpose for patients to receive virtual care via VVC. VA’s standard operating procedure
(SOP) includes eligibility criteria purposely left broad in light of the pandemic and does not require
scheduling the patient for a VVC appointment.110 After introducing the digital divide consult, VA
issued devices (iPads) to about 41,000 patients during the first three quarters of fiscal year 2021.
These devices were not always used to connect to video telehealth, as only an estimated 20,300 of
those patients (about 49 percent) with issued devices completed a VVC appointment. The
remaining patients (about 51 percent) had not used the devices for VVC appointments.
• An estimated 10,700 patients never had a VVC appointment scheduled, as there was no
requirement to schedule, and neither the patient nor the staff initiated scheduling a VVC
appointment.
• We estimated that more than 10,000 patients had a VVC appointment scheduled but did not
complete the VVC visit for various reasons, such as technical issues or a cancelation, and a
subsequent VVC appointment was not completed.
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We also found lapses in device issuance and management during the review of VA’s tablet
dashboard data. Specifically, we determined that VA staff did not retrieve about 8,300 unused
devices to make them available to other patients when they did not have VVC activity, as required by
the SOP. The value of the devices was about $6.3 million and cost VA about $78,000 in additional
cellular data fees during the period under review. When VA does not retrieve and update its loaned,
unused devices, it cannot make them available to other patients.
We also determined that as of January 2022, there was a backlog of about 14,800 returned
devices pending refurbishment before they could be redistributed. The returned devices
accumulated primarily because of technical issues with the refurbishment system VA used. As
a result, these devices were not logged into shippable inventory and were not available to be
distributed to other patients. Despite the backlog, VA did not suspend purchases of new devices
from its contractor and placed a purchase order for additional new devices in August 2021. As of
December 2, 2021, VA bought 9,720 devices under this purchase order, totaling about $8.1 million.
Regarding the positive value that this program provided veterans, VHA noted an April 2022 study
that found veterans with a history of mental health care use and in receipt of a video-enabled tablet
were associated with increased use of mental health services via video, increased psychotherapy
visits across all modalities, and reduced suicidal behavior and emergency department visits.111
VA-loaned devices represent a sizeable investment and should be closely monitored. The
importance of remote care has been highlighted by the COVID-19 pandemic and capitalizing on
the best use of resources set aside for video-based care will continue to be an important aspect of
this program and VA’s operations. We made recommendations for continued program development
relevant to oversight roles and responsibilities, revising standard operating procedures, enhancing
device monitoring and retrieval controls and oversight, implementing more detailed device
refurbishment reporting, and using such data when considering new device purchases.

CONCLUSION
VA operated a robust telehealth program prior to the pandemic. VA made a noticeable effort to
expand remote medical services that resulted in more veterans and beneficiaries being able to take
advantage of telehealth appointments, particularly during the COVID-19 pandemic. However, upon
review, we noted that there was room for improvement in telehealth and related services that would
reduce risk, free up funds, and improve the veteran experience.

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Department of Labor

Office of Workers’
Compensation Programs
DOL’s Office of Workers’ Compensation Programs (OWCP) administers four major disability
compensation programs that provide wage replacement benefits, medical treatment, vocational
rehabilitation, and other benefits to eligible workers, or their survivors, who experience work-related
injury or occupational disease:
1. the Federal Employees Compensation Act (FECA) program, which provides benefits to federal
employees injured on the job;
2. the Black Lung program, which provides benefits to coal miners who suffer from Black Lung
disease as a result of coal mine employment;
3. the Energy program, which provides benefits to Department of Energy (DOE) employees and
contractors, atomic weapons employees, and uranium workers exposed to toxic substances on
the job; and
4. the Longshore program, which provides benefits to injured employees engaged in maritime
work or in maritime occupations on the navigable waters of the United States or adjoining
areas.112
Workers who suffer work-related injury or occupational disease file a claim with the appropriate
workers’ compensation program. Eligible claims are approved for compensation and/or medical
benefits, with OWCP paying 100 percent of the cost for claimants. OWCP determines the
appropriateness113 of and sets payment rates for services required to treat any accepted medical
conditions. To bill OWCP for services, medical providers must enroll with OWCP, self-certify that
they meet all applicable federal and state licensure and regulatory requirements, and maintain
supporting documentation for the self-certification.
FECA Program: The FECA program covers approximately 2.6 million civilian federal employees,
including U.S. Postal Service employees, in more than 70 different agencies. The FECA program
pays for services, appliances, and supplies prescribed by a qualified physician that OWCP deems
likely “to cure, give relief, reduce the degree or the period of disability, or aid in lessening the
amount of monthly compensation”114 for the injured worker.
In Fiscal Year (FY) 2021, the FECA program provided $2.938 billion in benefits to more than
183,000 workers and survivors for work-related injuries or illnesses. Of these benefits payments,
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$771 million was for medical benefits and rehabilitation services.
Black Lung Program: The Black Lung program provides compensation to coal miners who are
totally disabled by pneumoconiosis115 arising out of coal mine employment. The program also
provides eligible miners with medical coverage for the treatment of lung diseases related to
pneumoconiosis. There are two parts to the program. Part B benefits are paid by the Federal
Government to miners and eligible survivors who filed a claim on or before December 31, 1973;
Part C benefits are paid by self-insured coal mine operators or insurance carriers for claims filed
after 1973. However, when no coal mine operator can be held liable for payments, the Federal
Government pays Part C benefits from the Black Lung Disability Trust Fund (Trust Fund), which is
primarily funded by an excise tax on coal produced and sold domestically. Part B benefits do not
include medical benefits. Miners who receive Part B benefits are required to file for medical benefits
under Part C. The Black Lung program does not maintain telehealth data on Part C benefits paid by
coal mine operators or insurance carriers; therefore, this report only includes telehealth information
on Part C benefits paid out of the Trust Fund.
In FY 2021, the Black Lung program served about 5,900 beneficiaries and paid approximately
$50.6 million under the Part B program; likewise, it paid over $149 million in benefits to about
15,500 Part C beneficiaries. The Black Lung program also monitored benefits paid by responsible
coal mine operators to another approximately 8,900 beneficiaries.
Energy Program: Part B of the Energy Employees Occupational Illness Compensation Act provides
a fixed amount of compensation and medical coverage to DOE employees and contractors, atomic
weapons employees, and uranium workers with specified medical conditions, including cancer.
Part E of the act pays variable cash benefits up to a maximum amount based on impairment and
wage loss and provides medical benefits to former DOE contractors and uranium workers exposed
to toxic substances on the job.
From the beginning of the program in July 2001116 to March 2022, the Energy program paid over
$13 billion in compensation for almost 134,000 claims and over $7.7 billion in medical benefits.
Longshore Program: The Longshore program offers workers’ compensation protection to
employees engaged in maritime work or in maritime occupations on the navigable waters of the
United States or adjoining areas. The Longshore program generally does not directly pay benefits to
injured workers.117 Rather, it oversees the award and delivery of benefits, which are provided by selfinsured private employers or insurance carriers. Because the Longshore program does not maintain
data on telehealth services provided by these self-insured employers and insurance carriers, the
Longshore program will not be included in this report.
Scope of DOL Review: This review describes telehealth services provided by physicians and
other medical practitioners. Telehealth services refer to services that are provided remotely using
technology between a medical provider and a claimant. This review includes data on telehealth
services provided by OWCP’s FECA, Black Lung, and Energy programs.
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OWCP TELEHEALTH POLICY CHANGES DURING THE PANDEMIC
As a result of the COVID-19 pandemic, the FECA, Black Lung, and Energy programs instituted new
policies that expanded access to telehealth for injured workers by allowing routine medical care to
be provided through telehealth by certain types of medical care practitioners. The Energy program
further expanded telehealth services, temporarily allowing physicians to evaluate claimants through
telehealth to determine a need for home health care or durable medical equipment. Prior to the
pandemic, only the FECA program allowed telehealth. See Exhibit 1 below.
Services: In 2020, the OWCP programs expanded access to telehealth at varying degrees. While the
FECA program had allowed telehealth prior to the pandemic, the Black Lung and Energy programs
had not. The FECA program did not have a formal telehealth policy prior to the pandemic, but in
October 2020, it instituted a new policy on telehealth services and published a list of 54 medical
procedures for which telehealth would be allowed.118 The services ranged from routine medical
appointments that normally take place in a doctor’s office to physical therapy and other virtual care
services, such as a telephone call with a provider to discuss a claimant’s medical condition.
The Black Lung program also started allowing telehealth for routine medical appointments during
the pandemic. In June 2020, the Black Lung program instituted a new policy allowing telehealth
for office visits, physical examinations, health screening, diagnostic testing, and treatment for
an illness or non-emergency medical condition. There are now 10 medical procedures for which
telehealth is allowed as routine medical care. The Black Lung program is currently in the process
of expanding telehealth beyond routine services. Additional services are currently being paid on an
exception basis, provided the bills are submitted with an acceptable place of service,119 acceptable
modifier,120 and the appropriate attachment for telehealth services.121
In April 2020, the Energy program established a new policy to temporarily allow telehealth for
physicians to provide routine non-emergency medical care and to evaluate claimants to determine
medical necessity for home health care and durable medical equipment. OWCP management
indicated the Energy program allowed 44 medical procedures for telehealth since implementation
of the policy. While the temporary telehealth policy for home health care and durable medical
equipment was extended until September 2022, the telehealth policy for routine non-emergency
medical care has been made permanent as of December 2021.
For all three OWCP programs, telehealth services can be provided through a real-time interactive
audio and video telecommunication system or through an asynchronous method, where medical
care is provided through video or image that is not in real-time. However, certain medical
procedures cannot be performed through audio only. For example, the Black Lung program requires
video communication for virtual services such as virtual check-ins and E-visits,122 and the Energy
program requires face-to-face evaluation using remote video conference with a nurse, nurse
practitioner, or physician assistant present to determine medical necessity for home health care
and durable medical equipment.

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Claimants and Providers: The OWCP programs have no limits on claimants receiving telehealth
services; however, each program has limited the types of providers who can use telehealth.
• The FECA program limits the types of medical practitioners who can provide telehealth
services to physicians, psychologists, social workers, chiropractors, occupational therapists,
physical therapists, and podiatrists;
• The Black Lung program allows physicians and other health care professionals who work
under a physician’s supervision to provide telehealth services when the medical care is
associated directly with an accepted medical condition; and
• The Energy program limits telehealth providers to licensed physicians.
OWCP does not require claimants to receive telehealth services only from providers with whom
they had an established relationship. Additionally, OWCP does not have an established network
of medical providers who participate in its programs. However, all medical providers, including
telehealth service providers, must enroll with OWCP. The providers must have legal and licensing
authority to provide telehealth services, self-certify that they satisfy all applicable federal and state
licensure and regulatory requirements applicable to their specific provider type, and maintain
documentation supporting the self-certification.
Payment Rates: In the three OWCP programs (FECA, Black Lung, and Energy), telehealth services
were paid the same as in-person services. Claimants are not responsible for any portion of
telehealth service costs. As a workers’ compensation program, the OWCP programs pay 100
percent of all allowed medical services, including telehealth services.

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Exhibit 1: Key Similarities and Differences in Telehealth Policies Among OWCP Programs During
the COVID-19 Pandemic123

+
$ $

FECA

Black Lung

Energy

Telehealth services
were allowed prior to the
pandemic, but there was
no formal policy.

Telehealth services were
not allowed prior to the
pandemic.

Telehealth services were
not allowed prior to the
pandemic.123

Claimants can receive
routine medical care
(emergency or nonemergency), including
physical and occupational
therapy, through telehealth
permanently.

Claimants can temporarily
receive non-emergency,
routine medical services
through telehealth until
further notice.

Claimants can receive nonemergency, routine medical
services through telehealth
permanently. Evaluations to
determine medical necessity
for home health care and
durable medical equipment
through telehealth was allowed
on a temporary basis.

No limitation on the
type of claimants who
can receive telehealth
services.

Physicians, psychologists,
social workers, chiropractors,
occupational therapists,
physical therapists, and
podiatrists can provide
telehealth services.

Physicians and other health
care professionals who
work under a physician’s
supervision can provide
telehealth services.

Only physicians can
provide telehealth
services.

Telehealth services can be
provided through a real-time
interactive audio and video
telecommunication system
or through an asynchronous
telecommunication system.

Telehealth services can be
provided through phone,
video conferencing, or
similar technologies.

For routine physician
appointments, telehealth
services can be provided through
phone, video conferencing,
or similar technologies.
Evaluations of medical necessity
must be conducted through
video conferencing with a nurse
or physician assistant present
with the claimant.

Providers are paid the
same rate as in-person
services.

Source: DOL OIG review of OWCP programs’ policies and interviews, 2022.

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TELEHEALTH USE IN OWCP PROGRAMS DURING THE PANDEMIC
During the first year of the pandemic, almost 16,000 OWCP claimants used
telehealth services.
From March 2020 to February 2021, almost 16,000 OWCP claimants used a telehealth service.
These claimants represented 10.9 percent of the more than 145,000 OWCP claimants, or about 1
in 10, who received any medical services during this period. This was a dramatic increase from the
prior year, when less than 1 percent of OWCP claimants—approximately 500—used telehealth.

OWCP claimants used 34 times more telehealth services during the first year of
the pandemic than they used in the prior year.
In total, from March 2020 to February 2021, OWCP claimants used about 58,000 telehealth
services. This amounted to 34 times more telehealth services than the prior year when only about
1,700 telehealth services were used. See Exhibit 2 for more details on the use of services for each
program.
Most of these telehealth services (about 55,000 in total or 95 percent) were used by claimants in
the FECA program. In total, OWCP paid over $7 million for telehealth services for claimants enrolled
in the FECA program, almost 34 times more than the approximately $209,000 it paid the prior year.

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Exhibit 2: Key Differences in Use of Telehealth Services During and Prior to the COVID-19
Pandemic in the OWCP Programs

FECA

BLACK LUNG

ENERGY

Almost 14,000 claimants, or
about 1 in 10, used telehealth
services during the pandemic,
compared to about 500 claimants
in the prior year.

237 claimants, or about 3 in 100,
used telehealth services during
the pandemic. Telehealth was not
an allowable service in the prior
year.124

Over 1,500 claimants, or about
1 in 10, used telehealth services
during the pandemic, compared to
7 claimants in the prior year.

Claimants received about 55,000
services via telehealth during the
pandemic, compared to almost
1,700 telehealth services in the
prior year.

Claimants received 336 services
via telehealth during the
pandemic. Telehealth was not an
allowable service in the prior year.

Claimants received about 2,400
services via telehealth during
the pandemic, compared to 10
telehealth services in the prior
year.

OWCP paid about $7 million,
or 1% of total medical benefits
payments, for telehealth services,
compared to about $209,000 in
the prior year.

OWCP paid about $27,000, or
0.2% of total medical benefit
payments. Telehealth was not an
allowable service in the prior year.

OWCP paid about $300,000, or
0.03% of total medical benefit
payments, for telehealth services,
compared to about $1,200 in the
prior year.

Source: DOL OIG analysis of OWCP telehealth data, 2022.

OWCP claimants most commonly used telehealth for office visits and behavioral
health services.
Together, these two service types accounted for 93 percent of all telehealth
services during the first year of the pandemic. As seen in Exhibit 3, office
visits—routine appointments with primary care providers or specialists—
accounted for 62 percent of all telehealth services. In addition, behavioral
health services accounted for about 31 percent of all telehealth services.
Behavioral health services include individual therapy, group therapy, and
substance use disorder treatment, among others. Other telehealth services
included physical, occupational, and speech therapy, as well as virtual care
services, such as telephone calls with a provider or interactions via an
online patient portal.

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Exhibit 3: Almost
62 percent of all
telehealth
services were
office visits, which are
routine appointments
with a primary care
provider or specialist.
Source: DOL OIG analysis of
OWCP telehealth data, 2022.

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Exhibit 4: Most claimants who
received telehealth services used
audio-video telehealth services

A vast majority of OWCP claimants who
received telehealth services used both audio
and video telehealth services.
A total of 669, or 4 percent, of all OWCP claimants
who received a telehealth service during the first
year of the pandemic, exclusively used one of
three covered telehealth services available only
via telephone.125 These three audio-only services
include telephone calls with a physician to discuss a
beneficiary’s medical condition. The vast majority of
claimants (96 percent) used audio-video telehealth
services. See Exhibit 4.

96% of
claimants who

received telehealth
services used
audio-video
service

Source: DOL OIG analysis of OWCP
telehealth data, 2022.

PROGRAM INTEGRITY RISKS ASSOCIATED WITH TELEHEALTH
Officials from all three OWCP programs indicated telehealth was not a significant part of their
program services or existing controls mitigated potential integrity issues. However, OWCP found,
through its analysis of medical benefit payment data, the following potential program integrity risks
associated with telehealth.

Program Integrity Risks Related to Payments and Costs
Telehealth providers may bill for services or supplies that were not rendered.
OWCP found providers could bill for services that may not have been provided. For example, a
provider billed for oral medication and topical products that were supposedly dispensed in person
by a physician when a shelter-in-place law was in effect and the claimants were probably not going
to the doctor’s office. In another instance, the service date of a physician dispensing medication to
a claimant in person coincided with the date of a “Zoom” telehealth service.
Another provider billed for services, such as acupuncture, that would need to be performed in an
office by a medical professional, during a period when the state was under a mandatory lockdown.
The provider indicated in the medical records that monthly evaluations of the claimant were
performed through telehealth.

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Telehealth providers may bill for services that are not necessary.
OWCP found there was an increase in spending for services such as durable medical equipment
attributable to providers that coincided with the move to telehealth services. For example, billing
records showed 76 percent of the amount spent in the FECA program on conductive garments
for electrical nerve stimulation from October 2019 to September 2020 was attributable to
prescriptions written by one provider—with nearly 92 percent spent in 2020. In one case, the
provider prescribed the conductive garment for the neck, back, shoulder, knee, and ankle when the
accepted medical condition was bilateral Carpal Tunnel Syndrome.126
Another provider who prescribed physical therapy for FECA claimants dramatically increased the
number of office visits billed after the pandemic began in early 2020. The number increased from
273 office visits billed in February 2020 to over 400 office visits billed in July 2020. Medical reports
indicated the office visits occurred via telehealth. The provider saw dozens of claimants multiple
times a week, but it was not clear to OWCP why the multiple visits were necessary.

Providers could upcode billing.
Telehealth providers may be using billing codes that reflect more expensive treatments than what
was provided to maximize reimbursement. For example, a provider billed a claimant using a billing
code for an initial consultation for critical care when the provider actually provided a virtual office
visit that was not an initial consultation, nor did it involve critical care.
Another provider treated a claimant twice weekly for 45 to 50 minutes, including phone
consultations, but used an inappropriate billing code that represented 60 minutes of psychotherapy
instead of a more appropriate 45-minute code.127 The billing record showed the provider had
consistently used the 60-minute billing codes for most of his cases. While there was not a
significant difference in the amount paid between the services, the psychologist was the top
provider that used this code in the FECA program.

Program Integrity Risks Related to Quality of Care and Patient Safety
Providers could treat claimants without required supervision.
Telehealth providers may be providing medical services to claimants without required supervision.
For example, a provider allegedly performed medical evaluations on claimants from a remote
location through telehealth using untrained and unsupervised technicians. Another provider, a
nurse practitioner, appears to have treated claimants without required physician supervision.

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Program Integrity Risks Related to Needed Data
Providers could bill for services provided through telehealth without appropriate
billing codes.
Telehealth providers may be submitting a bill for telehealth services without an appropriate place of
service code and/or modifier. OWCP noted that several providers supplied services via telehealth,
according to the medical records, but had not used a telehealth modifier when submitting bills.

Safeguards Against Program Integrity Risks
OWCP programs rely on bill payment processing edits and also monitor telehealth
data to safeguard against program integrity risks.
FECA program officials stated they had reviewed telehealth data and, based on the review,
established policies and procedures and implemented bill payment processing edits. They also
indicated they monitor potential program risks related to telehealth as identified and published
by law enforcement and regulatory agencies and as part of their ongoing surveillance protocol.
Black Lung program officials stated they review a random sample of medical bills, including bills
for telehealth services, as a part of their monthly internal audit process. They also indicated they
rely on edits in place to appropriately process bills for telehealth services. Energy program officials
stated they are monitoring telehealth utilization frequency against the frequency of in-person
services for aligned treatments and refer anomalies for further investigation. Officials from all
programs indicated they would reconsider and amend existing controls over telehealth services as
program integrity issues are identified.

ADDITIONAL SAFEGUARDS TO CONSIDER
OWCP should consider additional safeguards over data needed to identify
telehealth services, such as telehealth modifier codes.
While telehealth services are not a significant part of the OWCP programs, it is important for
OWCP to continue to monitor telehealth services as their use becomes more accepted and
widespread. However, in its analysis of medical benefit payment data, OWCP found many of the
bills for telehealth services did not include proper telehealth modifier codes. Our analysis of
OWCP’s telehealth data confirmed that 35 percent of the telehealth services provided during the
pandemic lacked telehealth modifier codes. Additionally, officials from the Black Lung program
expressed concern that they may not be able to identify and monitor telehealth service-related bills
if medical providers are not consistently using the telehealth modifier codes. OWCP should consider
developing additional guidance for providers to ensure the modifier codes are appropriately and
consistently used on medical bills.

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Department of Justice

DOJ Prisoner
health care services
The DOJ must ensure that federal prisoners in its custody are housed in humane facilities and
receive adequate health care.128 Depending on the location and needs of the individuals in custody,
DOJ can serve as either a direct provider or a payer of health services for its prisoners. DOJ prisoner
population totals are displayed in Exhibit 1.129
Exhibit 1: DOJ Prisoner Population Totals
The Federal Bureau of Prisons (BOP): Most
BOP prisoners are housed in BOP-operated
February 2020
February 2021
prisons (institutions), with smaller subsets of
the population housed at privately operated
BOP-operated
146,000
124,000
contract prisons and Residential Reentry
Institutions
Centers (RRCs, also known as halfway houses).
For prisoners housed in BOP-operated
USMS
65,000
64,000
institutions, the BOP provides health care
both through clinical staff working inside its
Source: DOJ OIG analysis of DOJ data, 2022.
institutions and through external health care
providers. BOP clinical staff can directly provide
health services to BOP prisoners in-person, though in certain situations BOP prisoners may also
receive care through internal telehealth visits via remote connection from the institution housing
the prisoner to a BOP clinical staff member working at another location.130 When needed, the
BOP can also connect its prisoners with outside medical care, including through telehealth with
external providers. The BOP generally uses comprehensive medical services contracts established
at individual BOP institutions to facilitate and pay for these external health services.131 Prisoners in
BOP custody have no financial obligation for telehealth care.
The United States Marshals Service (USMS): The USMS does not directly operate its own
detention facilities, nor do USMS staff directly provide medical care to prisoners. Instead, the
USMS relies on detention facilities to ensure that the USMS prisoners they house receive medical
care. Most USMS prisoners are housed in more than 800 different state and local facilities, under
intergovernmental agreements that the USMS arranges with state and local governments. Smaller
portions of the USMS prisoner population are assigned to privately operated contract facilities as
well as BOP institutions.132
Detention facilities, operated by either state and local governments or private contractors, generally
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have on-site clinical personnel who provide certain health care services. The cost for these health
care services is included in a negotiated rate that the USMS pays the operator of a detention
facility to house USMS prisoners. Detention facilities also rely on outside medical providers when
inmates require a level of care beyond that which can be provided by on-site clinical personnel.
These facilities may select providers from a network established by the USMS National Managed
Care Contract contractor. Not only does this contract establish a national medical preferred-provider
network, it also provides centralized medical claims processing and payment services for the
USMS. After the contractor processes and pays the claim, the USMS then reimburses the National
Managed Care Contract contractor.133 For the subset of USMS prisoners housed in BOP institutions,
the BOP is responsible for the costs of all medical care, including telehealth care, these prisoners
receive.
Scope of DOJ Review: This review describes telehealth services provided to federal prisoners.
BOP and USMS telehealth services refer to services that were provided remotely using technology
between a provider and a prisoner. This review includes data on telehealth services used by
USMS prisoners and by prisoners housed in BOP-operated institutions. The review scope includes
telehealth services provided between March 2020 and February 2021 and the year prior. See
Appendix F for the DOJ OIG’s methodology.

BOP AND USMS TELEHEALTH PRIOR TO AND DURING THE PANDEMIC
Although the BOP and the USMS had no policies specific to telehealth during the period under
review, both DOJ components responsible for the care of federal prisoners utilized telehealth prior
to and during the COVID-19 pandemic.134
BOP: The BOP has utilized telehealth for over two decades and continued to use it during the
pandemic. In the year prior to the pandemic, an estimated 91 of the BOP’s 122 institutions
conducted telehealth visits, based on OIG analysis of available BOP data.135 Although the BOP
does not document the technology used to conduct each telehealth visit in its records, the BOP
generally used telephone and video teleconferencing to conduct telehealth, including through
BOP-provided mobile telehealth carts equipped with video conferencing and medical device
integration capabilities to enable remote consultations. After March 2020, during the first year
of the pandemic, an estimated 99 BOP institutions conducted telehealth visits. Between March
2019 and February 2021, an estimated 106 BOP institutions had conducted telehealth visits.
The BOP ordered 60 mobile telehealth stations, and by late spring 2021 the BOP’s headquarters
had shipped 59 of the stations to various BOP institutions.136 These actions increased telehealth
availability at many institutions.
A change the BOP made during the pandemic involved credential verification and granting of
clinical privileges or practice agreements for providers. By the end of February 2021, the BOP
had issued two waivers during the pandemic of the BOP’s credentialing policy requirement for
certain telehealth providers to complete the BOP’s credential verification and granting of clinical

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privileges prior to delivering care to prisoners. In July 2021 and February 2022, the BOP issued
additional waivers to its credentialing policy that waived the requirement for institution Wardens to
sign clinical privileges or practice agreements and delegated privilege-granting authority for BOP
telehealth providers to the BOP Medical Director.137 The BOP issued these waivers to reduce the
administrative burden on its institution staff to process credentialing verifications during the public
health emergency while also expanding the pool of available telehealth providers by allowing them
additional time and flexibility to fulfill requirements for clinical privileges. Additionally, out-of-state
licensure waivers during the pandemic helped facilitate the use of telehealth at BOP institutions.
The BOP reported that the types of telehealth services available to BOP prisoners generally did not
change as a result of the pandemic. Additionally, the BOP reported that telehealth service payment
rates generally remained constant before and during the course of the pandemic.
USMS: USMS officials reported that the USMS permits and encourages the use of telehealth
services for its prisoners when available and appropriate, and that the USMS tries to maximize and
leverage the use of telehealth when and where possible. However, the USMS could not report which
telehealth services were available to USMS prisoners and whether availability changed after the
start of the pandemic because the USMS does not maintain a list of services that could be provided
using telehealth, or the patients or providers who could use telehealth services. According to our
analysis of USMS National Managed Care Contract contractor claims data, the USMS used four
telehealth service categories in the year prior to the pandemic, compared to eight telehealth service
categories during the first year of the pandemic. Examples of common telehealth services provided
to prisoners in USMS custody include office visits, virtual care services, and behavioral health.
The USMS did not report any changes to payment rates for telehealth services after the start of the
pandemic and indicated that telehealth services are reimbursed at no greater than the Medicare
rate, as required by law.138 Furthermore, there were no changes to the USMS National Managed
Care Contract due to the COVID-19 pandemic.

TELEHEALTH USE BY THE BOP AND USMS DURING THE PANDEMIC
Utilization of telehealth services increased in both the BOP and the USMS during
the first year of the pandemic.
In general, we found that while telehealth use was limited to small fractions of DOJ prisoners when
considered in relation to overall populations in custody, telehealth utilization increased for both BOP
and USMS prisoners during the first year of the pandemic compared to prior to the pandemic.139
During the first year of the pandemic, the proportion of prisoners housed in BOP-operated
institutions using telehealth more than doubled compared to the prior year. From March 2020
through February 2021, over 3,900 prisoners in BOP-operated institutions used telehealth services.
This figure represents approximately 3.2 percent of the approximately 124,000 prisoners housed in
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BOP-operated institutions at the end of February 2021.140 This is an increase compared to the year
prior, when over 1,900 prisoners, or approximately 1.4 percent of approximately 146,000 prisoners
housed in BOP-operated institutions, used telehealth.
During the first year of the pandemic, the proportion of USMS prisoners using telehealth increased
by a factor of nearly five when compared to the prior year, during which just over 0.1 percent of
prisoners used these services. During the first year of the pandemic, from March 2020 to February
2021, over 375 prisoners in USMS custody used a telehealth service.141 This figure represents just
under 0.6 percent of the approximately 64,000 prisoners in USMS custody at the end of February
2021.142 This is an increase from the year prior, when fewer than 80 prisoners, or approximately 0.1
percent of the approximately 65,000 total prisoners in USMS custody, used telehealth.
Based on available BOP data, prisoners in BOP-operated institutions used approximately 5,300
telehealth services during the pandemic—from March 2020 to February 2021 (see Exhibit 2). This
amounts to more than twice as many telehealth services compared to the year prior. As noted in the
DOJ OIG’s program integrity section of this report, BOP data limitations resulted in the OIG analyzing
incomplete records from two BOP-provided datasets to generate these estimates.
Prisoners in USMS custody used over four times more telehealth services during the first year of the
pandemic than during the year prior. Specifically, prisoners in USMS custody used 617 telehealth
services during the pandemic, from March 2020 through February 2021.
The BOP estimated that it paid at least $376,700 for external telehealth services during the first
year of the pandemic. We note that this was over 11 times more than what it paid during the year
prior; however, there were data limitations affecting the calculation of these cost estimates, which
likely under-represent the total costs of external telehealth services.143 These cost estimates reflect
only external telehealth services provided by outside providers at approximately four out of five BOP
institutions and do not include the cost of telehealth services delivered by internal BOP providers.144
The USMS paid over $68,000 for telehealth services used by USMS prisoners during the first year
of the pandemic, compared to over $10,100 for telehealth services in the year prior. In total, the
USMS paid over six times more during the first year of the pandemic than it paid during the year
prior. These cost estimates were generated using selected Current Procedural Terminology (CPT)
codes from the USMS National Managed Care Contract contractor claims data.

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Exhibit 2: Key Differences in BOP and USMS Prisoner Use of Telehealth Services Prior to and
During the COVID-19 Pandemic

BOP
Prior (March 2019 -- February 2020)

During (March 2020 -- February 2021)

~1.4% of prisoners
used telehealth services

~3.2% of prisoners
used telehealth services

Prisoners received
over 2,500 services
via telehealth

Prisoners received
approximately
5,300 services
via telehealth

USMS
Prior (March 2019 -- February 2020)

During (March 2020 -- February 2021)

~0.1% of prisoners
used telehealth services

~0.6% of prisoners
used telehealth services

Prisoners received
135 services
via telehealth

Prisoners received
617 services
via telehealth

Source: DOJ OIG analysis of BOP data and USMS National Managed Care Contract contractor claims data, 2022.
Note: As noted in the DOJ OIG’s program integrity section of this report, the BOP figures presented in this exhibit are estimates due to
BOP telehealth data limitations.

Telehealth was used in both the BOP and the USMS for a variety of services.
For specialty care delivered via telehealth, prisoners housed in BOP-operated institutions most
commonly used telehealth for psychiatry, cardiology, nephrology, and gastroenterology visits. Of
these telehealth categories, all but psychiatry represented external visits delivered by outside
providers only. Together, the four visit types listed above accounted for approximately 68 percent
of telehealth visits for specialty care during the first year of the pandemic.145 Visits for neurology,
infectious diseases, and urology accounted for an additional 13 percent of specialty care visits
conducted via telehealth. Psychiatry visits with internal BOP providers were the leading type of
telehealth visit for specialty care, accounting for 41 percent of specialty care visits.

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USMS prisoners most commonly used telehealth for office visits, virtual care services, hospital
visits, and behavioral health. Together, these four service types accounted for approximately 95
percent of telehealth visits during the first year of the pandemic. Office visits—routine appointments
with primary care providers or specialists—accounted for 55 percent of all telehealth services.
Virtual care services, such as telephone calls with a provider or interactions via an online patient
portal, accounted for another 18 percent of all telehealth services. Hospital visits, such as
professional services provided remotely to patients in an emergency department, or as a part of
observation, accounted for 13 percent of all telehealth services. In addition, behavioral health
services accounted for about eight percent of all telehealth services. Behavioral health services
include individual therapy and substance use disorder treatment, among others. Other telehealth
services included nursing home visits, dialysis services, and preventive services.

PROGRAM INTEGRITY RISKS RELATED TO TELEHEALTH SERVICES IN THE
BOP AND THE USMS
The changes in telehealth usage for prisoners in BOP and USMS custody, along with limited
available telehealth data and a lack of BOP and USMS telehealth policies, underscore the
importance of determining whether providers are billing for telehealth services appropriately, as well
as identifying ways to safeguard the programs and ensure quality of care.

Current Program Integrity Safeguards Used by the BOP and the USMS
The BOP and the USMS do not have safeguards specifically designed for telehealth, and instead rely
on safeguards that are in place for all medical services. Both the BOP and the USMS have certain
procedures to verify the accuracy of claims submitted for outside medical care provided to prisoners
in their custody, which also apply to claims for telehealth services.
BOP: The BOP has protocols established for the submission and approval of medical claims for
outside medical care provided to prisoners in BOP custody. The BOP requires that each institution
have a medical claims adjudication process to ensure that services billed by the contractor
were properly authorized and ordered by the institution, are appropriately coded in compliance
with Medicare coding policies (as applicable), are properly priced in accordance with terms and
conditions of the contract, and do not represent duplicate billings for payments already made. A
medical claims adjudicator determines the validity of the CPT codes and other data listed in the
claims to verify the accuracy of claims submissions.
USMS: The USMS National Managed Care Contract’s performance work statement requires the
National Managed Care Contract contractor to establish an anti-fraud program. This program
provides oversight of health care providers that identifies unusual patterns of care, over-utilization
of services, suspected billing practices, and other unusual patterns. In addition, USMS district
offices review and certify the bill of National Managed Care Contract contractor claims every month
before USMS headquarters reimburses the contractor for claims for services provided.
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Advantages of Telehealth for Individuals in Federal Custody
Personnel from the BOP and the USMS described several advantages of having telehealth as an
option in their custodial environments, both before and during the pandemic. Telehealth as a
mechanism of care allows for care of prisoners while they remain inside secure institutions. This
model for addressing certain health care needs mitigates safety risks when prisoners are removed
from secure custodial environments and transported to community settings for outside medical
care. Both BOP and USMS officials expressed views that telehealth was an option that offered
benefits to community safety.
Telehealth can also help promote continuity of care and access to care for this patient population.
For example, BOP providers working at institutions may help facilitate telehealth visits with outside
providers and share relevant prisoner medical information during the telehealth visit. Further, given
that many custodial institutions are in isolated locations, telehealth can serve as an option that
increases access to health care providers with necessary expertise. For example, at one USMS
contract detention facility that utilized telehealth during the pandemic, facility personnel explained
that telehealth afforded prisoners increased access to quality providers, especially given the
facility’s remote location.
Additionally, both BOP and USMS officials noted that use of telehealth instead of outside medical
trips could present cost savings for their health care programs, particularly given that outside care
generally requires personnel to transport prisoners to outside medical facilities. Personnel at one
BOP Federal Medical Center told the DOJ OIG that telehealth was cost-effective compared to outside
medical trips for routine care, which represented significant expenses for the institution.146
During the COVID-19 pandemic, telehealth provided the additional benefit of helping mitigate
the risk of COVID-19 transmission by limiting the potential for prisoners and staff to contract
or introduce COVID-19 in settings outside the custodial environment. As described by USMScontracted detention facility staff, telehealth generally reduced facility staff and prisoner exposure
to COVID-19, as telehealth limited the need to transport prisoners into the community for outside
health care.

Program Integrity Risks Related to Billing
Both the BOP and the USMS reimburse external providers for telehealth services delivered to
prisoners in their custody. The BOP’s historical challenges to oversee costs for outside medical
care, in addition to the BOP’s lack of full visibility into total telehealth costs, may present program
integrity risks for telehealth.

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BOP: Prior DOJ OIG work has identified
concerns regarding the BOP’s potential
overpayment for outside medical services
and the BOP’s ability to identify fraudulent
billing schemes.

Concerns Regarding Potential
Overpayment by BOP for Prisoner
Health Care Services

The BOP’s method for reimbursement of claims for
telehealth services delivered by outside providers is the
same as that for other types of outside medical care.
Although the DOJ OIG did not assess payment risks
specific to telehealth services, previous DOJ OIG audit
work has found that the BOP had limited oversight of
contract costs billed and paid related to medical billings
by contractors responsible for the provision of medical
services at BOP institutions. For example, a 2019 DOJ
OIG audit of a BOP-awarded comprehensive medical
services contract for services provided to a BOP-operated
institution identified weaknesses in the contract related to
the definition of contract requirements and establishment
of contract pricing methodology, as well as instances
in which contractor performance did not comply with
contract terms, resulting in the BOP paying the contractor
over $825,000 for out-of-network services and services
not covered by Medicare pricing without proper approval
of the prices billed.147 Further, the DOJ OIG issued a
February 2022 Management Advisory Memorandum
which found that the BOP potentially overpaid for medical
services provided to prisoners (see the text box).148

In February 2022, DOJ OIG issued a
Management Advisory Memorandum
which identified that at least one prime
Comprehensive Medical Services Contractor
sometimes selected and submitted to the
BOP medical service billing codes on behalf
of its subcontracted providers of medical
services, instead of having the providers
select such codes themselves. This approach
is inconsistent with the approach typically
used in traditional medical practices. The
DOJ OIG’s investigation into this issue
revealed that, when this Comprehensive
Medical Services Contractor selected the
codes for its subcontracted health care
providers, in almost every instance the
selected code represented the highest
level, or costliest, in the applicable series.
By contrast, when the subcontractor
health care provider selected the code, in
the overwhelming number of cases, the
subcontractor did not select the highest
level in the applicable series. The DOJ OIG
concluded that this resulted in the BOP
potentially overpaying for medical services
provided to prisoners.

The BOP’s challenges with its medical claim record maintenance could also raise program
integrity risks for telehealth, as the BOP lacks a national medical claims system capable of
centrally tracking total telehealth care costs across its 122 institutions. In December 2017, DOJ
OIG issued a Procedural Reform Recommendation for the BOP regarding the BOP’s incomplete
health care claims, which the BOP remained unable to fully close as of May 2022.149 The DOJ
OIG found that the BOP’s health care claims continued to be processed primarily through manual
methods. Further, DOJ OIG has found that the deficiencies with the BOP’s health care claims data
limited the BOP’s and other stakeholders’ ability to identify and respond to potentially fraudulent
billing schemes such as claims for services not rendered, duplicate claims, or inflated bills. As
of May 2022, the BOP had not yet fully implemented the DOJ OIG’s recommendation to ensure
that its adjudication vendor is able to reproduce on demand all necessary data elements used to
adjudicate the claims and to ensure that the universe of claims data is available to the BOP on
a national scale in a format that allows for thorough analysis and oversight.150 According to the
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BOP, as of May 2022, the BOP has awarded a medical claims adjudicator contract that requires
the vendor to describe and submit surveillance programs for detection and tracking of potential
fraud and abuse. The BOP further noted that such programs shall include real-time capabilities
for research, reporting, and alerts to identify potential fraud and abuse. Lastly, the BOP would be
contacted immediately upon the identification of fraud and abuse and receive a detailed report
of the findings. The current lack of a central claims system to track costs could present risks for
telehealth program integrity.

USMS: The National Managed Care Contract contractor maintains an anti-fraud
program on behalf of the USMS.
As discussed above, the USMS’s National Managed Care Contractor processes and pays claims for
prisoner telehealth care procured through outside medical providers. For this review, the DOJ OIG
did not assess the efficacy of the anti-fraud program, nor did we independently assess claims data
to determine fraud risks unique to the provision of telehealth care.

Quality of Care and Patient Safety
The BOP’s and the USMS’s insights into quality of care and patient safety for DOJ prisoners using
telehealth may be limited. The lack of telehealth specific policies and comprehensive telehealth
data for prisoners in DOJ custody could present risks to ensuring quality of care and patient safety.
Further, OIG analysis of available BOP telehealth data identified two potential areas of concern.

BOP: Although the BOP’s electronic health record system tracks referrals to
specialists, prior DOJ OIG work has identified challenges with the BOP’s ability to
assess medical care delivered by outside providers.
The lack of BOP telehealth policies and robust telehealth data could present barriers to the BOP’s
ability to assess the quality of its telehealth care. Further, prior DOJ OIG audit work has identified
issues with the BOP’s ability to assess comprehensive medical services contractor performance
related to the timely delivery of prisoner health care and quality of care. For example, a March
2022 audit of comprehensive medical services contracts awarded by the BOP found that the BOP
did not have a reliable, consistent process in place to evaluate either the timeliness of prisoner
health care or the quality of that care at several BOP institutions.151 According to the BOP, its Bureau
Electronic Medical Record (BEMR) system allows the BOP to review referrals to specialists and track
scheduling dates and other information.

Based on available BOP telehealth data for specialty care, the DOJ OIG identified
two potential risk areas that could potentially raise continuity of care concerns.
First, the DOJ OIG identified challenges with the BOP’s ability to schedule some telehealth visits for
specialty care within the timeframe that BOP personnel requested. Specifically, according to
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BOP-provided consultation request data, while 71 percent of specialty care telehealth visits
occurred no later than 1 week after the requested target date, 29 percent occurred more than a
week after the requested target date. Although most telehealth visits, or 85 percent, occurred no
more than 30 days after the scheduled target date, we found it concerning that 183 telehealth
visits appeared to have occurred over 3 months after the scheduled target date, including one visit
that occurred nearly 1 year after the target date, according to BOP records. Delays in scheduling
telehealth visits could potentially interfere with prisoners’ prompt access to telehealth care.
Second, the DOJ OIG identified some delays in the BOP’s entry of telehealth visit results into its
BEMR system. Although the BOP generally updated most of these records promptly (same day
for almost half of telehealth visits and within 1 week for 84 percent of visits), for a small subset
(1 percent) of telehealth visits, records were not updated for over a month. We identified some
concerning outliers for which it took the BOP more than 100 days to enter telehealth visit results
into BEMR for eight telehealth visits, including one visit for which it took the BOP 1 year to enter
the results into BEMR. Delays entering telehealth visit results into records could pose potential
challenges to ongoing BOP prisoner care.

USMS: The USMS’s lack of telehealth policies and comprehensive telehealth data
could pose quality of care oversight challenges.
With over 800 intergovernmental agreement facilities, in addition to multiple contract and BOP
facilities that house USMS prisoners, there is a significant variety of settings in which telehealth
services may be available to USMS prisoners nationwide. The lack of comprehensive telehealth
data and policies at the USMS, coupled with the USMS’s limited insight regarding telehealth
services available to USMS prisoners, even as telehealth usage has increased, could present risks
to the USMS’s ability to assess quality of care for telehealth services.

Additional Data Needed for Effective Program Management and Oversight
We found that both the BOP and the USMS have blind spots in available data that affect their
ability to gather a full picture of telehealth for prisoners in federal custody. Given the increases to
telehealth utilization since the start of the pandemic, it is increasingly important for DOJ officials
to have reliable information on the scope and costs of these programs. Further, given the potential
benefits of the use of telehealth to meet certain health care needs for prisoners, more complete
and reliable data on these programs is necessary.

BOP: Data limitations make it difficult for the BOP to track the number of
telehealth visits for prisoners in BOP custody and associated telehealth costs.
The BOP lacks a reliable method to calculate total BOP telehealth costs. Due to the lack of a
central claims system that would facilitate calculations of total telehealth costs, and the variety
of comprehensive medical services contracts established across the BOP’s 122 institutions, the
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BOP’s cost estimates do not account for telehealth costs incurred at nearly one-fifth of its facilities.
Additionally, available BOP telehealth utilization data does not contain cost information. Thus,
the BOP lacks a centralized and comprehensive picture of the costs associated with its use of
telehealth services.
In addition to the lack of definitive insight into telehealth costs, limitations associated with the
BOP’s BEMR system do not allow the BOP to identify and report the complete number of telehealth
visits with prisoners in BOP custody. The quality of data available depends on each BOP institution
accurately and timely recording telehealth visits in BEMR. Further, the BOP was unable to provide a
comprehensive and unduplicated dataset that would definitively capture the number of telehealth
visits with prisoners in the facilities it operates. The BOP also advised that it could not definitively
tell whether records from two potentially relevant datasets represented patient-to-provider
telehealth visits or asynchronous patient notes without completing individual chart reviews for
each record, which the BOP stated was not feasible. Limitations with BEMR limit the BOP’s visibility
into the number of prisoner-to-provider telehealth visits across its institutions. Further, one of the
telehealth datasets provided by the BOP does not provide insight into specific categories of care for
which the BOP uses telehealth to treat prisoners.

USMS: The USMS lacks comprehensive telehealth data and available data may
not account for all telehealth visits.
During our review we learned that at least one USMS detention facility contractor provides
telehealth care as an in-house service. This operator does not submit a claim for any in-house
telehealth care because, as described above, the costs of any in-house health care services
(whether virtual or in-person) are included in a negotiated rate that the USMS pays the detention
facility operator. Without separate data detailing in-house telehealth clinical encounters, the
USMS could not tell us the total number of in-house telehealth clinical encounters involving USMS
prisoners or the total number of prisoners that received care as an in-house service at this facility.
Further, USMS officials acknowledged that they do not know how many facilities offer telehealth
care as an in-house service. Without an understanding of how many facilities are providing
telehealth as an in-house service, as well as how many of the in-house services provided at these
facilities are conducted virtually, the USMS does not know the total number of its prisoners that
have received telehealth care.

The BOP and USMS also lack data regarding the number of prisoners who used
audio-only telehealth services.
Neither the BOP nor the USMS maintains data that distinguishes the number of prisoners who used
telehealth services using audio-only services compared to audio-video telehealth.

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NEEDED PROGRAM INTEGRITY SAFEGUARDS
Additional research is needed to assess the efficacy of telehealth services for prisoners in DOJ
custody. A significant challenge that we identified to the transparent and effective implementation
of telehealth in DOJ prisoner health care services centered on the lack of complete and reliable
data on these types of clinical encounters with individuals in custody. As discussed above, the
BOP’s telehealth data is limited and the USMS does not maintain complete information about
which USMS prisoners have access to telehealth care. Although both components reported that
they were working to enhance their recordkeeping in this area, these gaps in relevant data limit the
DOJ components’ ability to assess the utilization, appropriateness, cost-effectiveness, and efficacy
of telehealth in their programs. We believe that the BOP and the USMS should strengthen their
collection of telehealth data and conduct additional research to inform their use of telehealth and
safeguard program integrity for telehealth services provided to prisoners in their custody.

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APPENDIX A:
Department of Health and
Human Services

Medicare
METHODOLOGY

Scope | This review describes Medicare telehealth services provided by physicians and nonphysician practitioners during the first year of the pandemic (i.e., from March 2020 through
February 2021) and the year prior (i.e., from March 2019 through February 2020).152
Data Sources | The HHS OIG’s review included multiple data sources, including policies,
regulations, and statutes related to coverage of telehealth in Medicare; Medicare fee-for-service
claims and Medicare Advantage encounter data; HHS OIG hotline complaints; an interview with
CMS staff about program integrity efforts and a review of related CMS documentation; and a review
of ongoing and previous OIG work.
Nature and Use of Telehealth in Medicare | To describe the nature of telehealth during the first
year of the pandemic and the year prior, the HHS OIG reviewed relevant policies, regulations, and
statutes and identified differences related to services, beneficiaries, providers, and payment rates
between the two time periods.
In addition, the HHS OIG conducted analyses of claims and encounter data to determine the extent
to which Medicare beneficiaries used telehealth during the first year of the pandemic and the year
prior.153 To do this, we identified the services that Medicare approved for telehealth during the
pandemic, using Current Procedural Terminology (CPT) codes and Healthcare Common Procedure
Coding System (HCPCS) codes.154 We then identified claims and encounter data billed with these
CPT and HCPCS codes that had 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.155
Using these data, we determined the number of beneficiaries who used telehealth services and
the total number of telehealth services they used during the first year of the pandemic and the
year prior. We also calculated the total amount paid by Medicare for telehealth services. Payment
amounts are for beneficiaries in Medicare fee-for-service only; payment amounts are unavailable in
the Medicare Advantage encounter data.

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To determine the most common telehealth services, we grouped each service into a category based
on CMS’s service classification system and CPT codes and calculated the number of telehealth
services in each category.
To determine the number of beneficiaries who used audio-only telehealth services, we focused on
the six telehealth services that are available exclusively audio-only. These six audio-only services
do not include video; they consist of telephone calls with a provider for various durations to discuss
a beneficiary’s medical condition. We did not include the other telehealth services that can be
provided audio-only because it was not possible to distinguish whether they were provided audioonly or audio-video.
To determine the proportion of beneficiaries who received telehealth services only from providers
with whom they had an established relationship, we reviewed Medicare fee-for-service claims and
Medicare Advantage encounter data for telehealth services provided from March 2020 through
December 2020. We then determined if a beneficiary had an established relationship with a
provider by identifying the date of the first telehealth service with the provider and looking back to
January 2018 to determine if the beneficiary had a prior in-person visit or other service with that
same provider.156
Program Integrity Risks Associated with Telehealth | To describe the program integrity risks
associated with telehealth, we developed seven measures as indicators of possible fraud, waste,
or abuse. We developed these measures based on analyses of Medicare data and input from
OIG investigators. These measures focus on different types of billing schemes for telehealth that
providers may use to maximize their Medicare payments. For each measure, we set thresholds at
extreme levels that may indicate possible fraud, waste, or abuse. We then analyzed Medicare feefor-service claims and Medicare Advantage encounter data for the first year of the pandemic and
identified providers whose billing exceeded the threshold on at least one of the seven measures.
These providers had billing that poses a high risk to Medicare.157
To further identify potential program integrity risks, we reviewed complaints made to the HHS
OIG hotline. We reviewed the complaints related to telehealth made during the first year of the
pandemic and described the nature of these complaints.
We also interviewed CMS staff and reviewed CMS documentation about the safeguards they have in
place to prevent fraud, waste, and abuse related to telehealth.
Lastly, we reviewed ongoing and previous OIG work—including investigations—related to telehealth
to identify program integrity concerns, focusing on those related to billing, quality of care, and data.
We also identified recommendations that OIG has made to CMS related to program integrity.

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Limitations
None of the measures or hotline complaints 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.

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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APPENDIX B:
Department of Defense

TRICARE
METHODOLOGY

Scope | The DoD OIG evaluation describes telehealth services delivered through the TRICARE East
and West preferred provider networks in the continental United States. The evaluation covers the
first year of the COVID-19 pandemic (March 2020–February 2021) and the prior year (March 2019–
February 2020).
Data Sources | The DoD OIG’s evaluation used multiple data sources, including,
• DoD TRICARE Operation, Policy, and Reimbursement Manuals;
• DoD TRICARE governing and regulatory authorities;
• previous DoD OIG telehealth audit work;
• a DHA telehealth encounter summary report; and
• a summary of TRICARE private sector beneficiaries enrolled in the Prime and Select health
care plans.158
In addition, we interviewed DHA officials regarding their program integrity oversight activities related
to telehealth. We excluded TRICARE for Life telehealth claims from our review because the Centers
for Medicare & Medicaid Services is the payer of first resort. Therefore, these telehealth claims
would be double-counted.
Nature and Use of Telehealth in TRICARE | To understand the nature of telehealth during the first
year of the pandemic and the prior year, we reviewed DHA TRICARE policy manuals. This information
helped us identify important changes in telehealth policy for patients, providers, and services.
We also reviewed a DHA summary of telehealth claims data covering TRICARE private sector
beneficiaries enrolled in the Prime and Select health care plans.
In addition, using these data, we determined the number of beneficiaries who used private sector
telehealth services and the total number of telehealth services they used during the first year of the
pandemic and the prior year. We also calculated the total amount paid by TRICARE for telehealth
services for each 1-year period.

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Program Integrity Risks Associated with Telehealth | To describe the program integrity risks
associated with telehealth, we reviewed the DoD TRICARE Operations Manual, DoD TRICARE Policy
Manual, and 32 Code of Federal Regulations part 199, and interviewed DHA program integrity
officials. We also reviewed a DHA contractor oversight survey summary report. In addition, we
reviewed the 2020 DHA “Program Integrity Division Operational Report” and DHA’s response to our
data request regarding telehealth safeguards in place to prevent fraud, waste, and abuse. Finally,
we reviewed a prior DoD OIG audit report that focused on telehealth payment program integrity.159

LIMITATIONS
To provide timely information, we did not test the reliability of the TRICARE enrollment and funding
totals provided by DHA officials. However, to ensure the accuracy of the TRICARE enrollment
and funding totals, we reviewed the TRICARE Policy Manual and established telehealth claims
parameters in our request to the DHA. We determined that the TRICARE enrollment and funding
totals provided by the DHA were sufficient for the purpose of our review. We reviewed DHA policy
covering TRICARE Program integrity controls. However, we did not test the program integrity controls.
Additionally, DHA officials were not able to identify telehealth related issues on billing and payment
for services not provided or not medically necessary due to their restricted access to medical
records. The restriction from access to medical records also limited the DHA’s ability to identify
issues with higher level of service or length of service than what the practitioner provided or
was necessary, ordering medically unnecessary laboratory tests, durable medical equipment, or
prescription drugs. Due to the restrictions on medical record access, the DHA conducts audits of
claim data disassociated with medical records, and this limitation can only result in identifying overutilization of billing codes or hours exceeding a 12-hour day.

STANDARDS
The DoD OIG 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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APPENDIX C:
Office of Personnel Management

Federal Employees
Health Benefits Program
METHODOLOGY
Scope | This review describes Federal Employees Health Benefits Program (FEHBP) telehealth
services provided by physicians and non-physician practitioners during the first year of the
pandemic (i.e., from March 2020 through February 2021), the year prior (i.e., from March 2019
through February 2020), and the extended pandemic period (i.e., from March 2021 through
December 2021).160
Data sources | OPM OIG reviewed multiple data sources applicable to all FEHBP health insurance
carriers (carriers), including: OPM Healthcare and Insurance (HI) office’s FEHBP Carrier Letters;
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act); the Families First Coronavirus
Response Act (FFCRA); and the FEHBP Enrollment and Headcount Report. In addition, OPM OIG
reviewed claims data for one carrier from our claims data warehouse as well as responses to an
OIG telehealth survey sent to a selection of ten FEHBP carriers.
Nature and Use of Telehealth in the FEHBP | To understand the nature of telehealth services
during the first year of the pandemic and the year prior, OPM OIG reviewed relevant OPM HI
Carrier Letters to understand OPM HI’s telehealth guidance to FEHBP carriers. While OPM did
issue some general guidance, OPM itself does not set policies regarding the administration of
telehealth in the FEHBP. Rather, procedures are decided upon by each carrier, or in some cases,
by individual providers. Therefore, we also reviewed the CARES Act; the FFCRA; the Department
of Health and Human Services (HHS) Fourth Amendment to the Declaration Under the Public
Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID–19
and its republication; and the HHS Office for Civil Rights Notification of Enforcement Discretion for
Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency to
gain a better understanding of telehealth policies overall.
We also reviewed responses to a carrier survey in which we selected ten FEHBP carriers of varying
plan types and sizes, covering a large portion of the FEHBP member population, to understand how
carriers managed telehealth services, including but not limited to benefit coverage and exclusions,
claims processing and payments, and security and privacy concerns.

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Furthermore, we analyzed health insurance claims data from one large fee-for-service carrier to
identify trends, patterns, and/or concerns of interest. This carrier covers approximately 68 percent
of the FEHBP member population. We used Current Procedural Terminology (CPT) codes and
Healthcare Common Procedure Coding System (HCPCS) codes, modifier codes (i.e., 95, GT, GQ, or
G0), or a “place of service code” (i.e., 02) to identify claims for services delivered via telehealth.161
Using this data, we determined the number of members from one large carrier who used telehealth
services and the total number of telehealth services they used during the first year of the pandemic,
the year prior, and throughout the rest of 2021. We also calculated the total amount paid by this
carrier for these telehealth services.
To determine the most common telehealth services, we grouped each service into a category based
on the CMS Restructured BETOS Classification System (RBCS Taxonomy)162 and the CPT/HCPCS
codes in our claims data. After creating these groupings, we calculated the number of telehealth
services in each category.
To determine the proportion of members who received telehealth services from providers with
whom they had an established relationship, we reviewed FEHBP claims data for telehealth services
provided from March 2019 through December 2021. The carrier data we reviewed utilizes a specific
plan code to identify claims obtained through its contracted telehealth company’s portal (as
opposed to a local provider portal). All claims for this plan code were considered instances where
the member would not have had a prior relationship with this provider, because this telehealth
company’s portal assigns a physician to the patient at the time of service. This is in contrast to a
telehealth appointment scheduled through a local provider portal, which would be scheduled with a
member’s provider of choice, the same way as in-person appointments are scheduled.
Program Integrity Risks Associated with Telehealth | To describe the program integrity risks
associated with telehealth, we developed six measures as indicators of possible fraud, waste, or
abuse. We developed these measures based on analyses of FEHBP claims data and input from
OIG investigators. These measures focus on different types of billing schemes for telehealth that
providers may use to maximize their FEHBP payments. For each measure, we set thresholds at
extreme levels that may indicate possible fraud, waste, or abuse. We then analyzed FEHBP fee-forservice claims for the time periods specified in our scope above (dependent on the measure) and
identified providers whose billing exceeded the threshold on at least one of the six measures. These
providers had billing that poses a high risk to the FEHBP.
To further identify potential FEHBP integrity risks, we reviewed complaints made to the OPM OIG
fraud, waste, and abuse hotline. We reviewed all complaints related to telehealth and ultimately did
not identify any further risk measures from this review.
We also asked questions in our above-mentioned carrier survey regarding the safeguards carriers
have in place to prevent fraud, waste, and abuse related to telehealth.

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LIMITATIONS
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.

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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APPENDIX D:
Department of Veterans Affairs

Veterans Health
Administration
METHODOLOGY
Scope of analysis of telehealth services provided by VA providers | The time frames for our
review of telehealth services provided by VA providers are the year before the COVID-19 pandemic,
March 2019 through February 2020, and the first year of the COVID-19 pandemic,
March 2020 through February 2021. We did not include telehealth consultations between providers
because this type of care does not include real-time interaction with a patient. In addition, we
did not include VA’s remote monitoring home telehealth program, which provides remote case
management services for chronic health conditions.
We used the VHA Corporate Data Warehouse as the source for health care encounter data.
Telehealth encounters were identified by stop codes, as VHA defines telehealth encounters using
stop codes rather than CPT codes. Stop code is a VHA term used to characterize outpatient
clinical encounters. Modalities of care may include in-person, telephone, and video telehealth.163
We reviewed VHA’s list of stop codes and included those that indicated a synchronous encounter
between a provider and patient. Stop codes for group clinics were excluded. The included stop
codes were designated as primary care, behavioral health care, specialty care, or other ancillary
services for the purposes of reporting data for this report.
We are not able to report on the cost of telehealth provided by VA facilities at the time of this review.
Funds are allocated to VA medical centers based on workload, which incorporates the volume of
patients served and the complexity of care that is delivered. Fund allocation is based on previous
years’ data.
Scope of analysis of telehealth services provided in community care | For our review of
community care telehealth, we analyzed claims data from VA’s claims processing systems—Plexis
and CCRS. Our time scope was March 1, 2019, through December 31, 2021. We first identified all
claims that were paid and that were for professional care. Then, we analyzed claims that included
one or more of the following types of codes: (1) a telehealth modifier, (2) telehealth CPT code, or (3)
place of service code indicating telehealth, to identify claims for telehealth that veterans received
from community providers.164

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Finally, we grouped these claims by Berenson-Eggers Type of Service (BETOS) codes. These codes
are assigned for each Healthcare Common Procedure Coding System (HCPCS) code and were
developed for analyzing the growth in Medicare expenditures. Each HCPCS code was assigned to
only one BETOS code.
Telehealth Program Integrity Testing | To identify schemes for telehealth that could potentially
pose a high risk to VA, we developed testing strategies to indicate possible fraud, waste, or abuse.
We developed these strategies by analyzing community telehealth claims data, considering fraud
indicators applicable to the work, and consulting with VA OIG investigators.
First, we compared VA’s paid community care telehealth claims data and the CMS list of telehealth
services to identify the volume of ineligible telehealth services that VA paid for during the review
period. From this comparison, we identified ineligible claims as those with CPT codes that were not
on this list or did not occur within the time frames provided by CMS, and were not telehealth CPT
codes.
Second, we identified high-usage days. Exhibit 1 shows how we identified high-usage days.
Exhibit 1. Identifying High-Usage Days

Step 1

Step 2

Step 3

Defined time estimates
for telehealth services
by CPT using CMS Final
Rule Physician Times

Multiplied times (in
minutes) by telehealth
claim line total units
billed to understand total
time per claim line*

Aggregated volume using
data fields in the claims
to identify providers who
billed at least 18 or more
hours of telehealth services per day**

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
*We excluded any claims with payments per unit that were less than $1.
**We used the RENDERINGPROVIDERID and SERVICE DATE TO data fields.

Third, we identified high-intensity evaluation and management telehealth claims. The number of
these claims, and the number of providers with one or more such claims, were then calculated as
percentages of the total number of telehealth claims and providers, as described in Exhibit 2.

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Exhibit 2. Identifying High-Intensity Evaluation and Management Telehealth Claims

Step 1

Step 2

Defined high-intensity evaluation
and management codes for
telehealth services*

Selected relevant claims for analysis
using the CLAIMID field and the count
of providers with specific attributes.**

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
* We used the PROCCODE fields 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215.
**We included providers with at least one high intensity claim using the RENDERINGPROVIDERID and CLAIMID fields.

Finally, we took steps to identify potentially duplicate services, as seen in Exhibit 3.
Exhibit 3. Identifying Potentially Duplicate Services

Step 1

Step 2

Isolate duplicate claim lines billed on
different claims between Plexis and
CCRS, as well as duplicate claim lines
billed on different claims through only
one of these systems*

Consider claims that were both billed
and paid as telehealth, as well as
those billed and paid as in-person and
through telehealth

Source: VA OIG analysis of VA community care telehealth claims data as of December 2021.
* We looked for claims with different values in the CLAIMID field with the same values for veteran social security number (BOX1A),
community provider (RENDERINGPROVIDERID), date of service (SERVICE DATE TO, BOX24ATO), and CPT code (PROCCODE,
BOX24DCPT).

VA’s Digital Divide Program Integrity Testing | We leveraged existing work that assessed VA’s
digital divide program and specifically examined the consult workflow at VA medical facilities during
FY 2021, including the percentage of patients who completed a VVC appointment.165
We interviewed key officials from Connected Care who were primarily responsible for the digital
divide program and conducted virtual site visits with five regional network leads and staff from
the eight facilities in the sample. The site visits were to ascertain digital divide processes and
procedures, determine the national program office’s effectiveness at disseminating guidance,
and identify potential internal control gaps in the consult guidance and device management. The
sample review findings were discussed with VA medical facility staff to confirm the identified issues
and establish their causes.
We also analyzed VA-loaned device activity data from VA’s tablet dashboard to determine if each
patient who received a device in the period of review completed a VVC appointment or had one
scheduled. Interviews with telehealth coordinators at eight medical facilities helped us identify

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the controls in place for device issuance, monitoring, and return. We also conducted a site visit
and interviews with Connected Care officials and contractor and other VA staff to understand the
purchasing, refurbishment, and inventory processes.
Data Reliability | We took steps to assess the reliability of the data we used to report on VA’s use
of telehealth services and devices during the pandemic. We performed limited testing of the data
and found that they were sufficiently reliable for the purpose of this report.

STANDARDS
The VA OIG conducted this work 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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APPENDIX E:
Department of Labor

Office of Workers’
Compensation Programs
METHODOLOGY
Scope | DOL OIG evaluated telehealth services provided to claimants in OWCP’s FECA, Black Lung,
and Energy Programs during the pre-pandemic period (March 1, 2019, to February 29, 2020) and
the pandemic period (March 1, 2020, to February 28, 2021). OWCP does not maintain telehealth
data on benefits paid by self-insured employers or insurance carriers; therefore, this report does
not include data on the Longshore program, whose benefits are primarily provided by employers or
insurance carriers. Likewise, this report only covers services provided by the Black Lung program
that were paid out of the Black Lung Disability Trust Fund. Additionally, we excluded telehealth
services that did not reflect an interaction between a claimant and a provider to ensure consistency
with the PRAC’s definition of telehealth used for this report.166
Data sources | OWCP extracted telehealth services data from its Workers’ Compensation Medical
Bill Process (WCMBP) system using the following attributes to identify telehealth services:
• FECA program: place of service, telehealth modifier, provider type, and procedure code.
• Black Lung program: telehealth modifier and procedure code.
• Energy program: telehealth modifier and procedure code.
DOL OIG reviewed OWCP’s program policies and procedures, obtained information via interviews
and questionnaires, analyzed OWCP data, and reviewed OWCP referrals to OIG investigators.
Because OWCP lacked sufficient oversight processes and documentation to support controls
over the WCMBP system,167 we were unable to determine the overall reliability of the medical bill
payment data in the system. However, we performed procedures such as data testing for accuracy
and completeness and performed reconciliations of the telehealth services data. We determined
the data was sufficiently reliable for the purposes of this evaluation.
Number and types of telehealth services | DOL OIG used procedure codes, dates of service
information, and HHS OIG’s telehealth service categories to determine the number and types of
telehealth services provided during the pandemic and pre-pandemic periods.

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Number of claimants receiving telehealth services | DOL OIG used OWCP’s case numbers and
dates of service information to identify the distinct number of claimants who received telehealth
services during the pandemic and pre-pandemic periods.
Cost of telehealth services | DOL OIG calculated the cost of telehealth services during the
pandemic and pre-pandemic periods by using the amount paid by OWCP and the date of service.

LIMITATIONS
DOL OIG did not obtain units of service data, but counted the number of procedures billed to
determine the number of telehealth services provided to claimants. Consequently, the actual
number of individual services provided could be higher.

STANDARDS
DOL OIG conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by Council of the Inspectors General on Integrity and Efficiency.

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APPENDIX F:
Department of Justice

DOJ Prisoner
health care services
METHODOLOGY
Scope | The review describes telehealth services provided to prisoners in the custody of the Bureau
of Prisons (BOP) and United States Marshals Service (USMS) during the first year of the COVID-19
pandemic (March 2020 through February 2021) and the year prior (March 2019 to February 2020).
Data sources | The DOJ OIG’s review included multiple data sources, including: BOP and USMS
policies, guidance, and memoranda; BOP waivers; BOP and USMS documentation and written
responses to OIG requests; contract documentation related to the USMS’s National Managed Care
Contract and a privately operated USMS contract detention facility; statutes related to payments for
costs of health care services for prisoners in USMS custody and the collection of fees from federal
prisoners for health care services; interviews with BOP Central Office staff, BOP institution staff,
USMS Headquarters staff, USMS contract detention facility staff, USMS National Managed Care
Contract staff, and a USMS Detention Contract Manager; the BOP’s BEMR consultation request
data and clinical encounter note data; USMS National Managed Care Contract contractor medical
claims data; BOP-provided cost-estimate data generated by BOP comprehensive medical service
contractors; DOJ OIG hotline complaints; BOP public website population data; and a review of
previous OIG work.
Nature and Use of Telehealth in the BOP and the USMS | To describe the nature of telehealth
for prisoners in BOP and USMS custody during the first year of the pandemic and the year prior,
DOJ OIG reviewed relevant policies, guidance, memoranda, waivers, statutes, and documentation
provided by the BOP and the USMS. The DOJ OIG also conducted interviews of BOP and USMS staff,
in addition to USMS contract detention facility staff and USMS National Managed Care Contract
staff to inform this report section.
In addition, DOJ OIG conducted analyses of BOP-provided BEMR consultation request data and
clinical encounter note data with selected telehealth locations to estimate the extent to which
prisoners housed in BOP-operated institutions used telehealth during the first year of the pandemic
and the year prior. To do this, the OIG matched records between the datasets using unique prisoner
identifier numbers and proximate date fields.168

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Using these data, we estimated the number of prisoners in BOP-operated institutions who used
telehealth services and the total number of telehealth services they used during the first year of the
pandemic and the year prior. We also utilized BOP-provided cost estimates for external telehealth
services at BOP institutions with active comprehensive medical service contracts, based on Current
Procedural Terminology (CPT) codes selected by the BOP’s comprehensive medical services
contractors. In addition, the DOJ OIG conducted analyses of USMS National Managed Care Contract
contractor medical claims data to determine the extent to which USMS prisoners used telehealth
during the first year of the pandemic and the year prior. To do this, for the USMS, we identified the
services that Medicare approved for telehealth during the pandemic, using CPT codes. We then
identified claims billed to the USMS’s National Managed Care Contract with these CPT codes that
contained at least one of the following: a CPT code modifier (i.e., 95, GT, GQ, or G0); a “place of
service code” (i.e., 02, 10) that indicates the service was delivered via telehealth; or a care category
of “Virtual Care Services.” We aggregated this filtered list to count telehealth claims and patients
across care categories.
Using these data, we determined the number of USMS prisoners who used telehealth services and
the total number of claims corresponding to those services in the first year of the pandemic and
the year prior. A claim including multiple telehealth services was counted once. We also calculated
the total amount paid by the USMS for all telehealth services within each claim using the listed
Medicare amount.169
To determine the most common telehealth services for the USMS, we grouped each claim into
categories based on the Centers for Medicare & Medicaid Services service classification system
and CPT codes. We included a claim in multiple categories if it contained services so classified.
Program Integrity Risks Associated with Telehealth | We relied on the information described
above to inform this section. In addition, we analyzed BOP-provided BEMR consultation request
data for specialty care with a selected telehealth location to identify potential risk areas.170
Specifically, we calculated the number of days between the scheduled “target date” and “send
date” fields to identify potential scheduling issues.171 We also calculated the number of days
between the “send date” and “results date” fields to identify potential delays in entering visit results
into BEMR.172
We also reviewed DOJ OIG hotline complaints and previous OIG work related to BOP health care.

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LIMITATIONS
As discussed in the DOJ OIG’s program integrity section of this report, the BOP was unable to
provide a comprehensive and unduplicated dataset that would definitively capture the number of
telehealth visits with prisoners in facilities it operated. For example, a BOP official stated that a
single telehealth visit could be represented by multiple entries in the data they provided. Thus, the
DOJ OIG performed analysis to remove potential duplicates by removing entries that occurred within
the same 10 day window for a prisoner. Additionally, although we use the term “telehealth visit” in
our analysis of BEMR consultation request data to identify potential risk areas, the BOP noted that
it had no way to determine whether there were any records representing asynchronous interactions
rather than telehealth visits included in the dataset. Further, the telehealth datasets provided by the
BOP do not capture telehealth costs and the BOP lacks a national medical claims system capable
of centrally tracking total telehealth care costs across its 122 institutions. Telehealth cost estimates
provided by the BOP do not capture costs for internal telehealth services provided by BOP providers
or services at all BOP institutions.
The DOJ OIG’s analysis of USMS telehealth data was limited to USMS National Managed Care
Contract contractor claims data for services billed to the USMS. This dataset might not represent
the complete universe of telehealth services provided to prisoners in USMS custody, such as for
in-house services not billed to the USMS’s National Managed Care Contract contractor. We did not
assess the BOP and USMS telehealth data for fraud indicators. Any determination of fraud or an
overpayment would require additional investigation.

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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Endnotes

Endnotes
1

PRAC, Top Challenges Facing Federal Agencies: COVID-19 Emergency Relief and Response Efforts (as reported
by Offices of Inspectors General across government) (Washington, D.C.; June 2020) and PRAC, Update: Top
Challenges in Pandemic Relief and Response (Washington, D.C.; February 3, 2021).

The Veterans Health Administration provides care directly to eligible individuals through a national system of
medical centers and community-based outpatient clinics and under certain circumstances through providers in
the community. The DoD uses the Military Health System’s health care plan known as TRICARE to provide global
direct care to eligible individuals and contracted network providers in the purchased care sector. The DOJ’s
Federal Bureau of Prisons delivers health care directly to the individuals it serves and under certain circumstances
pays for care delivered by other providers in the community. The DOJ’s United States Marshals Service may
also under certain circumstances pay for care for individuals in its custody delivered by other providers in the
community, in addition to paying for care provided inside detention facilities through agreements it maintains with
those facilities.

VHA defines a user as an enrolled veteran who has used VA services within the previous three years. According to
the VHA Allocation Resource Center, over 5.6 million veterans were enrolled users of VA health care in March of
2020. vaww.arc.med.va.gov. (The website was accessed April 12, 2022. This is a VA internal website.)

Workers’ Compensation did not cover telehealth physical therapy in two of its three programs, and it did not cover
telehealth occupational and speech therapy in one of its programs.

Prior to the pandemic, Medicare did not cover physical, occupational, and speech therapy services, nor assisted
living visits, via telehealth. In addition, while the Federal Employees Health Benefits Program did not have a
policy that limited the types of services that could be used via telehealth, most insurance carriers reported that
prior to the pandemic, they covered fewer services via telehealth. In addition, the Veterans Health Administration
policies discussed in this section of the report describe the policies for telehealth services provided directly by VAemployed providers. The Veterans Health Administration’s Community Care program follows Medicare telehealth
policies.

The DOJ prisoner health care services do not have policies about audio-only telehealth; however, the Federal
Bureau of Prisons reported using the telephone to conduct telehealth.

Prior to the pandemic, beneficiaries were allowed to use virtual care services, as well as telehealth services
to address substance use disorder or end-stage renal disease, from their homes and in urban areas. In
addition, beginning January 1, 2020, Medicare Advantage had greater flexibility to provide telehealth services
to beneficiaries. For example, plans could provide services to beneficiaries in their homes and regardless of
beneficiaries’ geographic location.

The American Rescue Plan Act of 2021 allowed VA to reimburse veterans or waive copayments or other costsharing for care provided from April 6, 2020, through September 30, 2021.

Federal prisoners housed in state and local facilities in the United States Marshals Service’s custody can be
assessed reasonable fees for certain health care services.

Providers could choose to reduce or waive beneficiary copayments for telehealth services during the pandemic,
without being subject to administrative action. See HHS OIG, OIG Policy Statement Regarding Physicians and
Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for
Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak, March 17, 2020.

Prior to the pandemic, Medicare paid equivalent amounts for telehealth and in-person services under certain
circumstances.

The totals represent the aggregated number of individuals who used telehealth in each program. Individuals who
used telehealth in more than one program may be counted multiple times. Also note that data from the Federal
Employees Health Benefits Program includes the data from the largest insurer, which represents approximately
68 percent of individuals enrolled in all plans. In addition, data for the DOJ prisoner health care services, which
include data from the Federal Bureau of Prisons and the United States Marshals Service, are incomplete because
of data limitations.

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Endnotes
13

The percentage for the Veterans Health Administration is based on those veterans who are enrolled active users
who received telehealth services directly from VA providers.

Behavioral health services accounted for 31 percent of telehealth services in Workers’ Compensation and 33
percent of telehealth services in the Federal Employees Health Benefits Program.

Virtual care services are a type of telehealth service that is always provided remotely, unlike other types of
services that can also be provided in-person. Examples of virtual care services include telephone calls with a
provider or interactions via an online patient portal, and remote monitoring, such as weight and blood pressure
checks.

According to billing guidelines, the 45-minute code is used for 38 to 52 minutes of therapy, while the 60-minute
code is used for 53 minutes and beyond.

See HHS OIG, Principal Deputy Inspector General Grimm on Telehealth, February 26, 2021.

DOJ, Laboratory Owner Sentenced to 82 Months in Prison for COVID-19 Kickback Scheme, November 9, 2021.

DOJ, National Health Care Fraud Enforcement Action Results in Charges Involving over $1.4 billion in Alleged
Losses, September 17, 2021. See also DOJ, Laboratory Owner Sentenced to 82 Months in Prison for COVID-19
Kickback Scheme, November 9, 2021.

“Incident to” billing allows clinical staff who are directly supervised by a practitioner to bill for services under the
supervising practitioner’s identification number.

This report focuses on the use of telehealth between a patient and a provider; it does not include provider-toprovider interactions. This report does not focus on issues related to privacy and technology.

This review includes the telehealth services approved for payment by Medicare as of February 28, 2021. It does
not include telehealth services billed by institutions to Medicare Part A.

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. CMS does not include services that are
always provided remotely in its formal definition of telehealth services.

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 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, The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), accessed at https://www.
congress.gov/bill/116th-congress/house-bill/748/text on November 23, 2021. See also HHS Office of Civil Rights,
Bulletin: HIPAA Privacy and Novel Coronavirus, February 2020.

These policies apply to both Medicare fee-for-service and Medicare Advantage plans; however, Medicare
Advantage plans had the flexibility to offer extra telehealth benefits both prior to and during the pandemic.

Prior to the pandemic, beneficiaries could receive certain services, such as virtual check-ins, through audio-only.

Unlike in Medicare fee-for-service, beneficiaries enrolled in certain Medicare Advantage plans were allowed
beginning January 1, 2020, to receive telehealth services both from home and in urban areas.

For more detailed information about the use of telehealth during the pandemic, see HHS OIG, Telehealth Was
Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic, OEI-0220-00520, March 2022.

Payment information is not available for patients enrolled in Medicare Advantage.

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31

HHS OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had
an established relationship, OEI-02-20-00521, October 2021. This study looked at telehealth services used by
Medicare beneficiaries from March 2020 through December 2020.

HHS 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.

CMS cannot distinguish between audio-only and audio-video for these 86 services. In addition, Medicare
Advantage plans can offer additional telehealth services that may include audio-only services that cannot be
identified in the data. Further, CMS recently required providers to use a modifier to identify audio-only services for
the treatment of certain mental health conditions. See 86 FR 64996 (November 19, 2021).

It does not include program integrity risks related to cybersecurity or patient privacy.

For more detailed information about the measures and the providers we identified, see HHS OIG, Medicare
Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-20-00720, September
2022.

These measures do not include telemarketing schemes that do not involve billing for telehealth services. Those
telemarketing schemes—often referred to as telefraud—generally involve a phone call or other remote interaction
with a beneficiary to order or prescribe medically unnecessary testing, equipment, or prescriptions. See HHS OIG,
Principal Deputy Inspector General Grimm on Telehealth, February 26, 2021.

See HHS OIG, Principal Deputy Inspector General Grimm on Telehealth, February 26, 2021.

DOJ, Laboratory Owner Sentenced to 82 Months in Prison for COVID-19 Kickback Scheme, November 9, 2021.

DOJ, National Health Care Fraud Enforcement Action Results in Charges Involving over $1.4 billion in Alleged
Losses, September 17, 2021.

For additional information, also see Agency for Healthcare Research and Quality, The Evidence Base for
Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, May 2020.

C. Jones, C. Shoff, K. Hodges, C. Blanco, J. Losby, S. Ling, and W. Compton, “Receipt of Telehealth Services,
Receipt and Retention of Medications for Opioid Use Disorder, and Medically Treated Overdose Among Medicare
Beneficiaries Before and During the COVID-19 Pandemic.” JAMA Psychiatry, p. E9.

Medicaid is a health care program jointly administered by CMS and States that serves certain populations with low
incomes. Some Medicare beneficiaries are also enrolled in Medicaid. HHS OIG, Opportunities Exist To Strengthen
Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid, OEI-02-19-00401, September 2021.

CMS could distinguish audio-only for six telehealth services during our review period. Effective January 1, 2022,
CMS began requiring providers to use a modifier to identify audio-only services for the treatment of mental health
conditions. See 86 FR 64996 (November 19, 2021).

This lack of transparency for “incident to” billing also affects oversight of services provided in-person. See HHS
OIG, Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-2000720, September 2022.

Telehealth companies are companies that employ practitioners to provide on-demand telehealth services to
beneficiaries. Unlike other providers, telehealth companies do not offer in-person services. See HHS OIG, Medicare
Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-20-00720, September
2022.

HHS OIG, Many Medicare Beneficiaries Are Not Receiving Medication to Treat Their Opioid Use Disorder, OEI-0220-00390, December 2021.

Additionally, CMS is part of the Healthcare Fraud Prevention Partnership. 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.

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.

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50

Noridian, 01-058 Traditional Telehealth Notification of Medical Review, February 2022. See also, Noridian, 01-055
Audio Only Telehealth Services During the PHE Notification of Medical Review, February 2022.

See HHS OIG, Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI02-20-00720, September 2022. Also see HHS 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, and HHS OIG, Many Medicare Beneficiaries Are Not Receiving Medication to
Treat Their Opioid Use Disorder, OEI-02-20-00390, December 2021.

TRICARE Policy Manual 6010.60M, April 1, 2015.

Medicare Part A helps pay for inpatient care in a hospital or for a limited time in a skilled nursing facility. Medicare
Part B helps pay for services from doctors and other health care providers, outpatient care, home health care,
durable medical equipment, and some preventive services.

TRICARE Reimbursement Manual 6010.61M, April 1, 2015.

Title 32 Code of Federal Regulations (CFR) section 199.6.

The two contractors are responsible for managing the authorized private sector provider networks in the eastern
and western continental United States. For the purpose of this report, we will use the term “private sector
beneficiaries” to refer to beneficiaries only enrolled in TRICARE East and West within the continental United States.
See Appendix B for the DoD OIG’s methodology.

85 Fed. Reg. 27,921 (2020).

As of April 2022, these temporary changes are still in effect.

Report No. DODIG-2022-047, “Audit of TRICARE Telehealth Payments,” February 3, 2022.

The “originating site” is the location of the patient receiving telehealth services and must be an authorized health
care facility.

The “distant site” is the location of the health care provider providing telehealth services.

TRICARE Operations Manual 6010.59M, April 1, 2015.

TRICARE Policy Manual 6010.60M, April 1, 2015.

DHA, “Program Integrity Division Operational Report Calendar Year 2020,” June 10, 2021.

The managed care support contractors designed prepayment edits to prevent payment for non-covered and
incorrectly coded services and to select targeted claims for review prior to payment.

Report No. DODIG-2022-047, “Audit of TRICARE Telehealth Payments,” February 3, 2022.

Experience-rated fee-for-service carrier – A carrier whose future medical costs are based on its past experience,
which considers a carrier’s actual paid claims; administrative expenses (including capitated administrative
expenses); retentions; and estimated claims incurred but not reported that are adjusted for benefit modifications,
utilization trends, and economic trends.

Experience-rated health maintenance organization carrier – A carrier whose future medical costs are based on its
past experience, which considers its medical history and claims experience in determining premiums.

Community-rated health maintenance organization carrier – Community-rated organizations allocate risks evenly
across a community, based on the medical statistics of a community. This means that a premium is derived for the
entire community without regard to age, gender, or health and wellness.

Carrier Letter – Instructions or guidance from OPM to the FEHBP Carrier organizations to provide information,
instruction, and or guidance on various subjects published throughout any given year.

Health savings accounts – A type of savings account that lets you set aside money on a pre-tax basis to pay for
qualified medical expenses such as deductibles, copayments, coinsurance, and some other expenses.

Qualified high deductible health plan – A plan with a higher deductible than a traditional insurance plan. The
monthly premium is usually lower, but you pay more health care costs yourself before the insurance company
starts to pay its share (your deductible).

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Access portals – The carrier, patient, or provider portals allowing authorized users to access information about
care and treatment, enabling patients to access their electronic medical records (EMRs), and facilitating patientprovider communication by connecting with a doctor through a convenient electronic environment.

Continuity of care – Continuity of care is an approach to ensure that the patient-centered care team is
cooperatively involved in ongoing health care management toward a shared goal of high-quality medical care.
Continuity of care is concerned with the quality of care over time.

It does not include program integrity risks related to cybersecurity or patient privacy.

These measures do not include telemarketing schemes that do not involve billing for telehealth services. Those
telemarketing schemes—often referred to as telefraud—generally involve a phone call or other remote interaction
with a member to order or prescribe medically unnecessary testing, equipment, or prescriptions.

Source: Analysis of the OPM OIG Claims Data Warehouse; data analysis was based on claims data from one
carrier, covering approximately 68 percent of enrolled members.

See FEHBP Carrier Letters 2017-01, 2019-01, 2019-05, 2020-02, 2020-08, 2021-03, and 2021-05.

Program integrity safeguards – Controls put in place to combat FEHBP provider fraud, waste, and abuse.

Coordination of benefits – To determine which insurance plan has the primary payment responsibility and the
extent to which the other plans will contribute when an individual is covered by more than one health and/or
prescription plan.

Impossible days – A provider sees a large volume of patients in a day (e.g., an individual provider has billed for
more than 24 hours of time on a given date).

Preferred Provider – For the purposes of this analysis, a preferred provider is a provider who offers both telehealth
and in-person services, typically working in a brick-and-mortar setting, as opposed to a provider who exclusively
offers telehealth services through a telehealth company.

https://oig.opm.gov/contact/hotline

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

https://www.opm.gov/healthcare-insurance/healthcare/carriers/2016/2016-03.pdf

VA defines a user as an enrolled veteran who has used VA services within the previous three years. According to
the VHA Allocation Resource Center, over 5.6 million veterans were enrolled users of VA health care in March of
2020. vaww.arc.med.va.gov. (The website was accessed April 12, 2022. This is an internal website.)

VA medical benefits package includes inpatient and outpatient care, primary and specialty care, preventive care,
diagnostic and treatment services, long term care, mental health care, pharmacy benefits, and other services.
https://www.va.gov/healthbenefits/resources/publications/hbco/hbco_medical_benefits_package.asp (The
website was accessed April 29, 2022.)

Congressional Research Service, “Department of Veterans Affairs (VA): A Primer on Telehealth”, July 26, 2019.
https://crsreports.congress.gov/product/pdf/R/R45834 (The website was accessed August 25, 2021.)
Darkins, Adam. “The Growth of Telehealth Services in the Veterans Health Administration Between 1994 and
2014: A Study in the Diffusion of Innovation,” Telemedicine and e-Health, September 3, 2014. https://doi.
org/10.1089/tmj.2014.0143 (The website was accessed April 20, 2022.)

VA Directive 1914, Telehealth Clinical Resource Sharing Between VA Facilities and Telehealth from
Approved Alternative Worksites, April 27, 2020. VA defines telehealth as the “use of electronic information
or telecommunications technologies to support clinical health care, patient and professional health-related
education, public health, or health administration at a distance.”

Federal Register, “Authority of Health Care Providers to Practice Telehealth,” Vol 83, No. 92, May 11, 2018.
Congressional Research Service, Department of Veterans Affairs (VA): A Primer on Telehealth, July 26, 2019.
https://crsreports.congress.gov/product/pdf/R/R45834. (The website was accessed August 25, 2021.)

Congressional Budget Office, The Veterans Community Care Program: Background and Early Effects, October
2021.

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92

VA provides care to veterans through non-VA community care providers under certain conditions, such as when
care is not available at a VA facility. https://www.va.gov/communitycare/. (The website was accessed April 20,
2022.)

Ancillary health services aid in the diagnosis and treatment of medical conditions. VA ancillary services include,
but are not limited to, pharmacy, x-ray and imaging services, physical and occupational therapy, speech and
language pathology, and audiology. https://www.va.gov/healthbenefits/access/ancillary_services.asp (The
website was accessed April 22, 2022.)

We extended the period considered as the pandemic through December 2021 based on the availability of claims
data at the time of this review. These numbers are subject to increase as TPAs process and adjudicate additional
VA community care telehealth claims.

VHA Directive 1914, Telehealth Clinical Resource Sharing Between VA Facilities and Telehealth from Approved
Alternative Worksites, “This directive defines national standards and responsibilities for sharing health care
professional services across VHA facilities through telehealth.” The purpose of this directive was to “reduce
administrative requirements for telehealth program activation” while “maintaining quality processes that ensure
oversight of health care professional practice.” April 27, 2020. VHA Handbook 1100.19, Credentialing and
Privileging, October 15, 2012, and VHA Directive 1100.20, Credentialing of Health Care Providers, September 15,
2021, detail requirements for credentialing and privileging of health care providers within VHA.

VA’s Corporate Data Warehouse provides “high-performance business intelligence infrastructure through
standardization, consolidation, and streamlining of clinical data systems.” https://www.hsrd.research.va.gov/
for_researchers/cdw.cfm (The website was accessed July 7, 2022.)

According to CMS, telehealth is defined as routine office visits provided via synchronous, real-time audio and video
communication. CMS defines e-visits as asynchronous (not real-time) communication with a patient through a
patient portal or other online method.

CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, March 30, 2020.

Where numbers are rounded for reporting purposes, we extended the period considered as the pandemic through
December 2021 based on the availability of data at the time of the review and because the pandemic is ongoing.
These numbers are subject to increase as TPAs process and adjudicate additional VA community care telehealth
claims.

100 Because of rounding, these totals are not the sum of the data points detailed in Exhibit 5.
101 Berenson-Eggers Type of Service codes are clinical categories that can be used to analyze how Medicare
expenditures grow in a specific clinical area. Each unique code is assigned to each Healthcare Common Procedure
Coding System code. The codes include evaluation and management, procedures, and imaging.
102 VHA Directive 1100.20, Credentialing of Health Care Providers, September 15, 2021.
103 Medicare Payment Advisory Commission, “Report To The Congress Medicare Payment Policy,” March 2021.
104 Due to claims with more than one risk, the totals for each payment risk area do not sum to the total community
care telehealth payments. For example, a claim may have included an ineligible service on a high-usage day.
Appendix D provides additional details on the review’s methodology.
105 Appendix D provides additional details on the review’s methodology for this objective.
106 Our calculation of 23,400 providers includes all providers with at least one high-intensity claim.
107 The cost avoidance and recovery (and recoupment) reports include TPA cost avoidance and recovery data, such as
the analysis of claims identified as being overpaid for the period under review.
108 Assistant under secretary for health for operations (10N) memo, “Expanding Access to Telehealth for Veterans
through the Digital Divide Consult,” August 12, 2020. This summary of the Digital Divide program refers to work
included in VA OIG, Digital Divide Consults and Devices for VA Video Connect Appointments, Report No. 21 02668
182, August 4, 2022.
109 A digital divide consult can also be used to help veterans benefit from additional federal subsidies, in addition to
the video-capable device. The consult helps identify a need, and grant government subsidies, for reduced-cost
internet service for patients.

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Endnotes
110 VA’s Office of Connected Care, “Digital Divide Consult Process SOP [Standard Operating Procedure],” November
2020, retitled “Digital Divide Standard Operating Procedure” and revised May, July, and December 2021 and
February 2022.
111 Gujral, Kritee, PhD; et al. “Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among
Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic.” JAMA Network Open.
JAMA Network, April 6, 2022. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790743.
112 For reasons discussed later, the Longshore program will not be covered in this report.
113 For the Longshore program, the employers or the insurance carriers authorize medical treatment.
114 5 U.S. Code § 8103(a)
115 Coal workers’ pneumoconiosis, commonly referred to as black lung disease, is a lung disease caused by inhalation
of coal dust.
116 Part B of the Energy program went into effect on July 31, 2001, and Part E of the Program went into effect on
October 28, 2004.
117 For a small number of cases where both the responsible employer and its insurance carrier are insolvent or are
out of business, medical benefits are paid out of the Longshore and Harbor Workers’ Compensation Act Special
Fund (Longshore Special Fund). In FY 2021, the Longshore Special Fund paid medical benefits for 34 cases.
According to the Longshore program, it has not paid for any telehealth services out of the Longshore Special Fund.
118 In March 2021, the FECA program updated its telehealth policy to allow seven additional medical procedures and
removed three medical procedures that were previously allowed.
119 The Black Lung program requires the claimant’s address to be the delivery location for the delivery of medical care
via telehealth.
120 OWCP utilizes the following modifiers for telehealth services: GT (via interactive audio and video
telecommunications systems), GQ (via an asynchronous telecommunications system), and 95 (synchronous
telemedicine service rendered via a real-time interactive audio and video telecommunications system).
121 In addition to the bill for services, the Black Lung program requires the physician or health care provider to
provide the following information: a note stating the method of telemedicine used; any vitals or medical evidence
collected; and an outline of the medical need and benefit derived from the service, as it relates to the claimant’s
accepted condition.
122 E-visits allow patients to talk to their doctor using an online patient portal without going to the doctor’s office.
123 Although telehealth was not specifically authorized prior to the pandemic, the Energy program paid for the services
if appropriate for the medical condition.
124 Although telehealth was not allowed prior to the pandemic, the Black Lung program retroactively paid $47 for
one telehealth service provided to one claimant on February 20, 2020, because the bill was received after the
President of the United States declared COVID-19 a National Emergency on March 13, 2020.
125 OWCP covered the following three procedure codes related to telephone evaluation and management services by
a physician or other qualified health care professional: 99441 (a 5- to 10-minute discussion), 99442 (an 11- to
20-minute discussion), 99443 (a 21- to 30-minute discussion).
126 Carpal Tunnel Syndrome is a condition that causes pain, numbness, or tingling in both hands and fingers at the
same time.
127 According to billing guidelines, the 45-minute code is used for 38 to 52 minutes of therapy, while the 60-minute
code is used for 53 minutes and beyond.
128 The Federal Bureau of Prisons (BOP) and the U.S. Marshals Service (USMS) are the DOJ components responsible
for the custody and care of federal prisoners. The BOP is responsible for confining federal prisoners in controlled
environments that are safe and secure and must also ensure that prisoners are housed in humane facilities and
receive adequate health care. The USMS is responsible for providing safe, secure, and humane custody, housing,
medical care, and transportation to prisoners awaiting trial or sentencing decisions.

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Endnotes
129 BOP population totals account for prisoners housed at BOP-operated institutions only. The total number of
prisoners housed at BOP-operated institutions, contract prisons, and Residential Re-entry Centers (RRCs) was
approximately 175,000 at the end of February 2020 and 152,000 at the end of February 2021. USMS population
totals include all USMS prisoners. The total number of USMS prisoners housed in non-BOP institution settings was
approximately 55,000 at the end of February 2020 and February 2021.
130 The BOP does not capture the costs of these internal encounters independently from the salary expenses of its
personnel in these roles.
131 According to the BOP, telehealth telephone services are not a line item in comprehensive medical services
contracts awarded at BOP institutions. The BOP may complete contract enhancements for telehealth services at
BOP institutions.
132 Pursuant to a memorandum of understanding between the BOP and the USMS, the BOP is responsible for all
costs, including medical costs, associated with housing USMS prisoners in BOP facilities.
133 Prisoners housed in state and local facilities may also be assessed reasonable fees for medical services other
than those addressing preventive health care services, emergency services, prenatal care, diagnosis or treatment
of chronic infectious diseases, mental health care, or substance abuse treatment. See 18 U.S.C. § 4013(d).
134 As of September 2022, the BOP reported that it was developing a draft policy specific to telehealth.
135 To estimate the number of telehealth visits at BOP institutions, the OIG matched records between two BOPprovided datasets. The telehealth visit figures presented in this paragraph are estimates due to BOP data
limitations.
136 The BOP retained one of the mobile telehealth stations for use at BOP headquarters.
137 These waivers also no longer required institutions to maintain institution-specific privileges and practice
agreements. The BOP’s February 2022 waiver stipulated that external telehealth providers follow contract
requirements, that the comprehensive contract holder verify external telehealth provider credentials, and that
current credentials for external telehealth providers be available for review by BOP institutions.
138 See 18 U.S.C. § 4006(b)(1). Note: the pricing stipulations in this statute do not include the BOP.
139 According to the BOP, the vast majority of health care services are provided onsite at institutions.
140 Although the DOJ OIG is using the snapshot prisoner populations as of the end of February 2020 and February
2021 to compare relative proportions of prisoners who used telehealth services, the total number of prisoners
who were in BOP-operated institutions would likely vary from the 146,000 and 124,000 figures because of
prisoner flows in and out of the system during the years in question. The prisoner population in BOP-operated
institutions decreased during the first year of the pandemic.
141 The USMS National Managed Care Contract contractor claims data did not include data on telehealth services
provided to USMS prisoners housed in BOP-operated institutions, as the BOP is responsible for the costs of
medical care provided to those prisoners.
142 Although the DOJ OIG is using the snapshot prisoner populations as of the end of February 2020 and February
2021 to compare relative proportions of prisoners who used telehealth services, the total number of prisoners in
USMS custody during those years would likely vary from the 65,000 and 64,000 figures because of prisoner flows
in and out of the system during the years in question.
143 The BOP provided these estimates based on CPT codes selected by the BOP’s comprehensive medical services
contractors to represent external telehealth care, at institutions with an active comprehensive medical services
contract. However, these estimates likely under-represent the total costs of external telehealth services because
only 80 percent of BOP institutions, approximately, had an active comprehensive medical services contract as
of April 2022. The BOP’s selection of CPT codes to estimate the cost of telehealth services differs from the CPT
codes used to estimate the USMS’s telehealth costs.
144 As noted above, in certain situations prisoners in BOP custody may also receive care through internal telehealth
visits with BOP-employed providers via remote connection from the institution housing the prisoner to a BOP
clinical staff member working at another location.
145 Due to BOP data limitations, this analysis is specific to categories of telehealth care for specialty care only, as the
BOP provided more descriptive categories for specialty care delivered via telehealth.

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Endnotes
146 Federal Medical Centers provide care to prisoners in need of more advanced medical or mental health care,
compared to prisoners housed in other BOP institutions. Six of the BOP’s 122 institutions are Federal Medical
Centers.
147 DOJ OIG, Audit of the Federal Bureau of Prisons’ Contract Awarded to Correct Care Solutions, LLC for the Federal
Correctional Complex in Coleman, Florida, Audit Report 19-37. The OIG closed all recommendations from this
report in August 2021.
148 DOJ OIG, Notification of Concerns Regarding Potential Overpayment by the Federal Bureau of Prisons for Inmate
Health Care Services, Investigations Management Advisory Memorandum 22-035. The scope of the Management
Advisory Memorandum included one Comprehensive Medical Services contractor. In June 2022, the OIG
closed its recommendation to the BOP to establish and implement a plan to ensure that all current and future
Comprehensive Medical Services contractors use CPT/Healthcare Common Procedure Coding System codes
selected by their contracted service providers when submitting requests for reimbursement to the BOP rather than
choosing such codes themselves.
149 DOJ OIG, Procedural Reform Recommendation for the Federal Bureau of Prisons, Investigations Procedural
Reform Recommendation, 2016-008873.
150 According to the BOP, as of May 2022, the BOP has included the adjudication language in all new comprehensive
medical services requirements (new solicitations). The BOP further noted that it will complete bill adjudication
modifications to existing contracts.
151 DOJ OIG, Audit of the Federal Bureau of Prisons Comprehensive Medical Services Contracts Awarded to the
University of Massachusetts Medical School, Audit Report 22-052.
152 This review includes the telehealth services approved for payment by Medicare as of February 28, 2021. It does
not include telehealth services billed by institutions.
153 For more information on this analysis, see HHS 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.
154 The codes used in the analysis include 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.
We also included virtual care services as a type of telehealth service. These services are also referred to as
Communication Technology-Based Services. They 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. See
85 FR 19230 (April 6, 2020) and 85 FR 84472 (December 20, 2020).
155 All virtual care service codes were considered as being provided via telehealth, as these services can only be
provided remotely.
156 For this analysis, we considered providers with the same billing identification number—such as those in the
same medical practice—to be the same. For more information about this analysis, see HHS OIG, Most Medicare
beneficiaries received telehealth services only from providers with whom they had an established relationship,
OEI-02-20-00521, October 2021.
157 For more information about these measures, see HHS OIG, Medicare Telehealth Services During the COVID-19
Pandemic: Program Integrity Risks, OEI-02-20-00720, September 2022.
158 TRICARE Operations Manual 6010.59M, April 1, 2015. TRICARE Policy Manual 6010.60M, April 1, 2015. The DHA
telehealth encounter summary report is a summary of the encounter data from the Military Health System Data
Repository, which included TRICARE beneficiary telehealth encounters and expenditures for telehealth claims.
159 Report No. DODOIG-2022-047, “Audit of TRICARE Telehealth Payments,” February 3, 2022.
160 This review includes the telehealth services incurred as of December 31, 2021.
161 All virtual care service codes were considered as being provided via telehealth as they can only be provided
remotely.
162 Categories based on the Restructured BETOS Classification System as of August 20, 2021, which can be found
at https://data.cms.gov/provider-summary-by-type-of-service/provider-service-classifications/restructured-betosclassification-system.

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Endnotes
163 The primary stop code is a three-digit number which designates the clinical group responsible for the care
provided to a patient. The secondary stop code serves as a modifier to further describe the clinical work, such as
the telehealth modality of care.
164 Telehealth claims were identified if it had a Place-of-Service code of 02, or a modifier of 95, G0, GQ, or GT.
Telehealth CPT codes - claim lines billed with the following telehealth CPT codes - G0071, G2012, G2010, 99421,
99422, 99423, G2025, G2061, G2062, G2063, 98966, 98967, 98968, 98969, or Q3014.
165 VA OIG, Digital Divide Consults and Devices for VA Video Connect Appointments, Report No. 21 02668 182,
August 4, 2022.
166 We excluded 4,377 telehealth services paid by OWCP with the following procedure codes: 99080 (Special
Reports), 99367 (Medical Team Conference), and S9999 (Sales Tax).
167 For more information, please see: Alert Memorandum: The Office of Workers’ Compensation Programs’ Workers’
Compensation Medical Bill Process System Data Were of Undetermined Reliability, DOL OIG Report No. 23-22002-04-001.
168 As noted in DOJ OIG’s program integrity report section, the BOP advised that it could not definitively tell whether
records from the two datasets represented patient-to-provider telehealth visits. To estimate the number of
telehealth services and prisoners in BOP-operated institutions who used telehealth, the OIG counted matches
between the datasets that appeared in certain categories.
169 As noted in the DOJ OIG’s program integrity report section, these figures represent only the costs of telehealth
services billed to the USMS National Managed Care Contract and might not represent the total costs of all
telehealth services provided to prisoners in USMS custody.
170 We analyzed all records in this dataset for this analysis.
171 The scheduled target date is the date by which BOP personnel would have preferred for a visit to occur, and the
send date is the date a telehealth visit occurred.
172 The results date is the date that visit results were entered into BEMR.

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Acknowledgments

Acknowledgments
This report was prepared under the guidance of the PRAC Health Care Subgroup, chaired by HHS
Inspector General, Christi A. Grimm, and led by HHS OIG in collaboration with DoD OIG, OPM OIG,
VA OIG, DOL OIG, DOJ OIG, and PRAC professional staff. Special acknowledgments to the following
staff who collaborated on this report:
HHS OIG: Jodi Nudelman, Miriam Anderson, John Gordon, Vincent Greiber, Alexis Mills, Erin Bliss,
Megan Tinker, and Andrew VanLandingham.
DoD OIG: Maurice Foster, Kaleab Tesfaye, Matthew Worner, Emil Kabban, Towanda Meredith,
Laurel Gosmen, and Kevin Acosta.
OPM OIG: Stephanie Oliver, Jasmine Taylor, Michael Weaver, and Dawn Schauer.
VA OIG: Jennifer Baptiste, MD; Irene J. Barnett, Ph.D.; Kim Cragg; Benjamin Howe; Julie Kroviak,
MD; Patrice Marcarelli, MD; Daniel Morris; Andrea Sandoval; Leigh Ann Searight; and David Vibe,
MBA.
DOL OIG: Brittany Arias, Dennis Asante, Nicholas Christopher, Richard Fitzgerald, Y.C. Lee, Jon Ling,
and Stephen Sovich.
DOJ OIG: DOJ OIG team.
PRAC: Marc Geller, Mey McLean, Jarrett Fussell, and Emily Bond.

Pandemic Response Accountability Committee

117

For more information:
Department of Health and Human Services,
Office of Inspector General
Office of Public Affairs
Public.Affairs@oig.hhs.gov

Department of Defense,
Office of Inspector General
Office of Public Affairs
Public.Affairs@dodoig.mil

Office of Personnel Management,
Office of Inspector General
Faiza Mathon-Mathieu, Chief of Policy,
Legislative & External Affairs
Faiza.Mathon-Mathieu@opm.gov

Department of Justice,
Office of Inspector General
Stephanie Logan, Communications Director
Stephanie.Logan@usdoj.gov

Department of Veterans Affairs,
Office of Inspector General
Fred Baker, Public Affairs Officer
Fred.Baker@va.gov

Department of Labor,
Office of Inspector General
Erin Zickafoose, Director, Office of
Congressional and Public Relations
Zickafoose.Erin@oig.dol.gov

Pandemic Response Accountability Committee
Lisa Reijula, Associate Director of Outreach and Engagement
Lisa.Reijula@cigie.gov

Visit us at:

PandemicOversight.gov

@COVID_Oversight

Report Fraud, Waste, Abuse, or Misconduct:
To report allegations of fraud, waste, abuse, or misconduct regarding
pandemic relief funds or programs please go to the PRAC website at
PandemicOversight.gov.

A Committee of the
Council of the Inspectors General
on Integrity and Efficiency

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Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic

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