Watchdog: Federal Healthcare Programs Vulnerable to Telehealth Billing Risks

As telehealth use exploded across healthcare programs provided by federal agencies, a report by a watchdog committee shows several program integrity risks linked to telehealth billing, including duplicate billing and ordering unnecessary durable medical equipment or laboratory tests.

The report, released by the Pandemic Response Accountability Committee's (PRAC) Health Care Subgroup, examines telehealth use within selected healthcare programs across six federal agencies during the first year of the COVID-19 pandemic. The agencies are Medicare, TRICARE, Federal Employees Health Benefits Program, Veterans Health Administration (VHA), Office of Workers' Compensation Programs, and the Federal Bureau of Prisons and U.S. Marshals Service, also known as the DOJ prisoner healthcare services.

The PRAC Health Care Subgroup comprises six Offices of Inspectors General (OIGs) who collected data on telehealth use from March 2019 through February 2020 and from March 2020 through February 2021.

They found that approximately 37 million individuals used telehealth services from March 2020 through February 2021 in the selected programs administered by the six federal agencies. This represents a massive increase from the 3 million individuals in these programs who used telehealth services the year prior.  

In most programs, telehealth was used primarily to access office visits with a primary care provider or specialist and for behavioral health services, like individual and group therapy and substance use disorder treatment.

Overall, the agencies spent more than $6.2 billion on telehealth services, with Medicare accounting for the highest expenditure at $5.1 billion, followed by TRICARE and the Federal Employees Health Benefits Program, which together spent $1 billion.

But the OIGs found several similar program integrity risks associated with billing for telehealth services across multiple programs. These included "upcoding" telehealth visits by billing for visits longer than they lasted, duplicate billing for the same service, ordering unnecessary durable medical equipment, supplies, or laboratory tests, and billing for services inappropriate or ineligible for telehealth.

The report provided examples of the above risks, including that the Department of Health and Human Services OIG identified more than 300 Medicare providers who billed for telehealth services at the most expensive level every visit, totaling approximately $5.2 million. Further, the VHA paid roughly $1.5 million for about 14,000 possible duplicate telehealth claims.

In addition to the program integrity risks associated with billing, the OIGs also found that there is limited information about the impact of telehealth on healthcare quality. This could pose challenges to patient safety, with one of TRICARE's contractors identifying 89 potential telehealth-related care quality issues during the first year of the pandemic, up from seven the previous year.

The OIGs also noted missing data that is needed to oversee telehealth billing, including data on audio-only services and data inaccurately identifying telehealth services as in-person services.

The report provides several recommendations for additional safeguards that could help improve program integrity.

Some suggestions include programs conducting ongoing monitoring of telehealth services, developing additional billing controls like pre-payment edits, closing data collection gaps to safeguard against fraud, waste, and abuse, and collecting information on the quality of telehealth-enabled care.

The report's publication follows growing calls to Congress to make permanent telehealth policy flexibilities enacted during the pandemic.

In September, a group of 375 healthcare stakeholders signed a letter by the American Telemedicine Association asking Congress to solidify expanded telehealth access for the next two years. The stakeholders included Amazon, the American Nurses Association, Ascension, Bicycle Health, and Cleveland Clinic.

Further, a recent survey shows that a majority of respondents (82 percent) with employer-provided coverage want the government to extend telehealth flexibilities. This includes a bipartisan majority of Democratic voters (95 percent), independent voters (77 percent), and Republican voters (70 percent).