The studies are part of a series that examines the use of telehealth in Medicare and the characteristics of beneficiaries who used telehealth during the pandemic.
The Office of Inspector General (OIG), in response to changes to Medicare telehealth policies due to COVID-19, on Wednesday released two new reports that highlight the dramatic increase in the use of telehealth and program integrity risks.
The first data brief describes providers' billing for telehealth services and identifies ways to safeguard Medicare from fraud, waste, and abuse related to telehealth. OIG said the information can help the Centers for Medicare & Medicaid Services (CMS), Congress, and other stakeholders determine safeguards to put in place as they consider permanent changes to telehealth policies in Medicare.
To conduct the study, OIG analyzed Medicare fee-for-service claims and Medicare Advantage encounter data for the first year of the pandemic from March 1, 2020, to February 28, 2021. Researchers focused their analysis on 742,000 providers who billed for a telehealth service and developed seven measures that focused on different types of billing for telehealth that may indicate fraud, waste, or abuse. Each set of measures has high thresholds to identify providers whose billing poses a high risk to Medicare.
Analysts identified 1,714 providers whose billing for telehealth services during the first year of the pandemic poses a high risk to Medicare. These providers billed for telehealth services for about half a million beneficiaries. They received a total of $127.7 million in Medicare fee-for-service payments. OIG said each of the providers had concerning billing on at least one of seven measures that may indicate fraud, waste, or abuse of telehealth services. All the providers warrant further scrutiny. For example, they may be billing for telehealth services that are not medically necessary or were never provided.
In addition, more than half of the high-risk providers the OIG identified are a part of a medical practice with at least one other provider whose billing poses a high risk to Medicare. This may indicate that certain practices are encouraging such billing among their associated providers. Forty-one providers whose billing poses a high risk appear to be associated with telehealth companies; however, the OIG said there is currently no systematic way to identify these companies in the Medicare data.
To address these concerns, OIG recommends strong, targeted oversight of telehealth services. The watchdog suggests that CMS 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 the telehealth service, identify telehealth companies that bill Medicare, and follow up on the providers identified in the report. CMS agreed with the recommendation to follow up on the providers identified in the report but did not explicitly indicate whether it concurred with the other four recommendations.
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The second data brief released this week expands on a previous analysis that found the use of telehealth increased dramatically during the first year of the pandemic. More than 28 million Medicare beneficiaries—about two in five—used telehealth services that first year. In total, beneficiaries used 88 times more telehealth services during the first year of the pandemic than they did in the prior year.
The latest research digs further into the characteristics of beneficiaries who used telehealth during the first year of the pandemic. OIG said the information provides insight on how the temporary expansion of telehealth affected different groups of beneficiaries. The findings may help CMS, the Department of Health and Human Services (HHS), Congress, and other stakeholders understand who benefited from the expansion and make decisions about whether temporary changes should become permanent.
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To conduct the research, OIG examined Medicare fee-for-service claims data, Medicare Advantage encounter data, and data from the Medicare Enrollment Database to focus on Medicare beneficiaries who used telehealth services during the first year of the pandemic, from March 1, 2020, to February 28, 2021.
The report found that:
- Beneficiaries in urban areas were more likely than those in rural areas to use telehealth during the first year of the pandemic.
- Beneficiaries in Massachusetts, Delaware, and California were more likely than beneficiaries in other states to use telehealth.
- Dually eligible beneficiaries (those eligible for both Medicare and Medicaid), Hispanic beneficiaries, younger beneficiaries, and female beneficiaries were also more likely than others to use telehealth.
- Beneficiaries almost always used telehealth from home or other non-health-care settings.
- One-fifth of beneficiaries used certain audio-only telehealth services, with most of these beneficiaries using these audio-only services exclusively.
- Older beneficiaries, dually eligible, and Hispanic beneficiaries were more likely to use these audio-only services.
OIG recommends that CMS take steps to enable a successful transition from current pandemic-related flexibilities to well-considered long-term policies for the use of telehealth for beneficiaries in urban areas and from the beneficiary's home, temporarily extend the use of audio-only telehealth services and evaluate their impact, require a modifier to identify all audio-only telehealth services provided in Medicare, and telehealth to advance health care equity. CMS did not explicitly indicate whether it concurred with the recommendations.