$3.7M in telehealth payments didn't meet Medicare requirements, OIG finds

Almost a third of telemedicine claims sampled by HHS' Office of Inspector General did not meet Medicare requirements, resulting in an estimated $3.7 million in unnecessary spending by the CMS.

The OIG reviewed 191,118 claims from 2014 and 2015 for distant-site telehealth services that resulted in payments of about $13.8 million. Of a representative sample of 100 claims, the OIG found that 31 claims did not meet Medicare requirements. Most of those 31 did not qualify because the patients received care in locations not considered rural.

Along with geographic restrictions, Medicare requirements stipulate that, for a telehealth claim to qualify for payment, the patient must receive the services at a qualifying originating site (not at home), the providers must be licensed to provide telehealth services, the patient and provider communicate in real time, and the service rendered is among those covered.

Besides problems with the originating site, other providers in the OIG's sample submitted claims for services that weren't covered and for services provided via communication that's not allowed. One provider, for example, submitted a claim for a psychotherapy service that's not covered. Another used a telecommunications service that didn't support real-time communication between the patient and provider.

In general, limited reimbursement has hindered providers' use of telemedicine. Medicare reimbursement has broadened slightly, though, with the February passage of the Chronic Care Act, which expands the services for which telehealth could be reimbursed by Medicare.

But some providers don't know how Medicare telehealth requirements work, the OIG found. In response, the OIG recommended that the CMS conduct education sessions to teach providers about the requirements.

The CMS has already been teaching healthcare providers about correct billing for telehealth, according to a CMS spokesperson.

The OIG also recommended that the CMS review claims after they've been paid to make sure there were no errors.

Hospitals should take note that they may be under increased scrutiny, said Nathaniel Lacktman, a partner and healthcare lawyer with Foley and Lardner.

"It's not something to play fast and loose with," he said. "You should do a bit of your homework on the front end."

In particular, hospitals should make sure that their patients are indeed in rural locations. An easy way to do that, Lacktman said, is by consulting the Medicare Telehealth Payment Eligibility Analyzer.