Insights on Telehealth Use and Program Integrity Risks in DOL Workers' Compensation Programs During the Pandemic

Summary

Memorandum report no. 19-23-002-04-001, dated December 13, 2022, from Carolyn R. Hantz, Assistant Inspector General for Audit at the U.S. Department of Labor Office of Inspector General, to Christopher J. Godfrey, Director of Workers' Compensation Programs. As part of a Pandemic Response Accountability Committee (PRAC) effort, it examines telehealth use in DOL's workers' compensation programs during the first year of the COVID-19 pandemic and identifies emerging program integrity risks. The OIG compared the pre-pandemic period (March 1, 2019, to February 29, 2020) with the pandemic period (March 1, 2020, to February 28, 2021) for the FECA, Black Lung and Energy programs. It reports that the pandemic led these programs to expand telehealth access, and that all three saw dramatic increases in telehealth use.

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U.S. Department of Labor Office of Inspector General
Washington, DC 20210

December 13, 2022

MEMORANDUM FOR: CHRISTOPHER J. GODFREY
Director of Workers’ Compensation
Programs

FROM: CAROLYN R. HANTZ
Assistant Inspector General
for Audit

SUBJECT: Insights on Telehealth Use and Program
Integrity Risks in DOL Workers’ Compensation
Programs During the Pandemic
Report Number: 19-23-002-04-001

As part of the Pandemic Response Accountability Committee’s (PRAC)1 effort to
provide policymakers and stakeholders with information about the nature of
telehealth and its use across federal health care programs, the Office of
Inspector General (OIG) conducted an evaluation to: (1) examine the use of
telehealth across the Department of Labor’s (DOL) workers’ compensation
programs during the first year of the COVID-19 pandemic, and (2) identify
emerging risks related to the use of telehealth.2 The PRAC previously identified
access to telehealth as a top challenge facing federal agencies in their COVID-19

1
The PRAC was created by the Coronavirus Aid, Relief, and Economic Security Act to support
and coordinate independent oversight of more than $5 trillion in pandemic relief programs and
spending. For more information, visit: https://www.pandemicoversight.gov/.
2
We evaluated telehealth services provided by the Federal Employees’ Compensation Act, Black
Lung, and Energy programs. Because the Office of Workers’ Compensation Programs does not
maintain telehealth data on benefits paid by self-insured employers or insurance carriers, our
evaluation did not include telehealth services in the Longshore program. Likewise, our evaluation
only covered services provided by the Black Lung program that were paid out of the Black Lung
Disability Trust Fund.

Working for America’s Workforce
response efforts in both 2020 and 2021.3 OIGs from six federal agencies
participated in this effort.4

To complete this evaluation, we reviewed the Office of Workers’ Compensation
Programs’ (OWCP) policies and procedures, obtained information via interviews
and questionnaires, analyzed OWCP telehealth services data, and reviewed
OWCP referrals to OIG investigators. We evaluated telehealth services provided
by OWCP during the pre-pandemic period (March 1, 2019, to February 29, 2020)
and the pandemic period (March 1, 2020, to February 28, 2021).5 We conducted
the evaluation in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and
Efficiency.

This memorandum provides a synopsis of our findings on the use of telehealth
services and related program integrity risks specific to DOL’s workers’
compensation programs. For additional information and context on telehealth
services in DOL’s workers’ compensation programs and in the selected health
care programs from the five other participating federal agencies, see the PRAC’s
federal telehealth report, “Insights on Telehealth Use and Program Integrity Risks
Across Selected Health Care Programs During the Pandemic,” issued on
December 1, 2022.6

Telehealth Use in OWCP Programs During the Pandemic

As a result of the COVID-19 pandemic, the Federal Employees’ Compensation
Act (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.

Dramatic Increase in Use of Telehealth. All three workers’ compensation
programs experienced dramatic increases in the use of telehealth during the first
year of the pandemic compared to the prior year. From March 2020 to

3
These two PRAC reports were: Top Challenges Facing Federal Agencies: COVID-19
Emergency Relief and Response Efforts (June 2020); and Update: Top Challenges in Pandemic
Relief and Response (February 3, 2021).
4
In addition to the Department of Labor, the other participating agencies were the Department of
Health and Human Services, the Department of Defense, the Office of Personnel Management,
the Department of Veterans Affairs, and the Department of Justice.
5
The participating OIGs determined the pre-pandemic and pandemic periods for the evaluation.
6
PRAC, Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care
Programs During the Pandemic (December 2022); available at:
https://www.pandemicoversight.gov/oversight/our-publications-reports/what-we-learned-about-
federal-telehealth-programs

-2-
February 2021, OWCP claimants used about 58,000 telehealth services. This
amounted to 34 times more telehealth services than the prior year when about
1,700 telehealth services were used.

Used Mostly by FECA Claimants. Most of the telehealth services during the
pandemic (about 55,000 or 95 percent of total telehealth services provided) were
used by claimants in the FECA program. Black Lung claimants used
336 services via telehealth, and Energy claimants used about 2,400 services.

Paid over $7.3 Million. For claimants enrolled in the FECA program, OWCP
paid about $7 million for telehealth services, which was almost 34 times more
than it paid the prior year. For the Energy program, OWCP paid about $300,000
during the pandemic compared to just $1,200 in the prior year.7 For the Black
Lung program, OWCP paid about $27,000 during the pandemic—telehealth was
not an allowable service in the prior year.

Used Mostly for Office Visits and Behavioral Health Services.
Ninety-three percent of all telehealth services during the first year of the
pandemic were for office visits and behavioral health services. Office visits
included routine appointments with primary care providers or specialists.
Behavioral health services included 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.

Program Integrity Risks Associated with Telehealth

All three OWCP programs indicated they saw no additional risk associated with
telehealth compared to in-person services because either telehealth was not a
significant part of the program services or existing controls mitigated the potential
integrity issues. However, OWCP found, through its analysis of medical benefit
payment data, the following potential program integrity risks associated with
telehealth:

 Providers may bill for services or supplies that were not
rendered. For example, a provider billed a claimant for oral
medication and topical products that were dispensed in-person by a
physician; however, a shelter-in-place law was in effect and the
claimants were probably not going to the doctor’s office.
 Providers may bill for services that are not necessary. For
example, a provider who prescribed physical therapy dramatically
increased the number of office visits billed after the pandemic

7
Although telehealth was not specifically authorized prior to the pandemic, the Energy program
paid for the services if appropriate for the medical condition.

-3-
began early 2020. Medical reports indicated the office visits
occurred via telehealth.
 Providers could upcode billing. For example, a 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, which reflected more
expensive treatment instead of a more appropriate 45-minute code.
 Providers could treat 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.
 Providers could bill without appropriate billing codes. OWCP
noted that several providers supplied services via telehealth,
according to the medical records, but had not used a telehealth
modifier when submitting bills.

Additional Safeguards to Consider

OWCP programs rely on medical bill payment processing edits and also monitor
telehealth data to safeguard against program integrity risks. 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, the
Black Lung program expressed concern that it 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.

We appreciate the cooperation of the OWCP staff involved in this evaluation. If
you have any questions regarding this report, please contact Stephen C. Sovich,
Audit Director, via email at sovich.stephen@oig.dol.gov.

cc: David Barrie, Branch Chief, Division of Financial Administration (DFA)
Michael A. Chance, Director, Division of Coal Mine Workers’
Compensation
Nancy J. Griswold, Deputy Director, OWCP
Rachel D. Pond, Director, Division of Energy Employees Occupational
Illness Compensation
Antonio Rios, Director, Division of Federal Employees’, and Longshore
and Harbor Workers’ Compensation
Jatin Wahi, Financial Management, DFA

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