Patients appreciate the convenience of telehealth, but fraud is a concern

During the COVID-19 crisis, policy makers, payers and providers alike explored new and innovative ways to increase patient access to care. As one of the largest payers in the United States, the Centers for Medicare and Medicaid Services (CMS) introduced several policy waivers and expansions related to telehealth services. Telemedicine usage exploded, with providers seeing 50 to 175 times the number of patients via telehealth than before the pandemic. 

As we enter the post-pandemic era, the volume of telemedicine visits may decrease, but this form of healthcare is here to stay. Although telehealth offers many benefits for patients, especially people in rural areas, it introduces operational complexities for providers and it also creates legitimate concerns about fraud for payers. 

Telemedicine visits are fairly new for many providers and in a way, they’re like the Wild West. No one is 100% sure what processes to use, which regulations are in effect and what technologies they should use. Unfortunately, these uncertainties can lead to unintentional fraud. 

For example, some providers may not have a clear procedure for authenticating patient identity before a telehealth visit. As a recent Healthcare Financial Management Association article noted, this could lead to identity theft and medical fraud. Best practices are to require patients to show a photo ID when scheduling a telemedicine appointment or to request that patients show an ID during their visit. Both of these measures should be documented in the patient’s record. 

Another risk area for physicians is using consumer-grade video conference software like Zoom, Skype or FaceTime for telehealth consultations. Although these software solutions were permitted by CMS during the COVID-19 public health emergency (PHE), they proved to be very attractive to cybercriminals. Hackers have exploited security holes in consumer-grade software to capture email addresses for phishing attacks and ransomware attacks. To combat this problem, patients need to be educated about safe computer practices. However, that alone is not enough. 

Once CMS eliminates the PHE waivers, providers must invest in HIPAA-compliant video-conferencing solutions, if they want to continue to offer telemedicine services. Other short-term recommendations to reduce the risk of cyberattacks include enabling encryption and privacy settings on consumer-grade software. 

In addition to cyberattacks, payers may encounter two types of telemedicine-related fraud:

1. True fraud. For example, unethical clinicians may upcode phone calls, virtual check-ins or e-visits to more expensive full telehealth sessions. Some may bill for services that they never rendered. These forms of fraud can be addressed using familiar tools like program integrity services, advanced analytics and special investigation units.
    
2. Indirect telehealth fraud. Criminals may use telehealth as a low-effort way to harvest valuable patient information. These bad actors often collude with telemarketers to contact huge numbers of people. The goal is to entice them to participate in a telehealth session and provide their personal information. Once an individual’s personal data has been stolen, the criminals use it to fraudulently bill government programs. For instance, they may bill for unnecessary durable medical equipment or a variety of cancer, genomic, pharmacogenetic or allergy tests. Stopping indirect telehealth fraud requires tailored analytics plus a deep understanding of how these schemes operate. 
    

Looking ahead, researchers and thought leaders are considering different ways to address telehealth-related fraud. Paths forward include creating data standards that would support interoperability across telehealth platforms, as well as taking algorithms used today to detect healthcare fraud and extending them for use with telehealth services. 

For years, HMS has worked with clients to meet CMS’s definition of payment integrity which is simply “pay it right.” In the weeks and months to come, we will continue to help payers meet this goal as they reimburse providers for telehealth services. To learn more about our payment integrity solutions, feel free to contact us. 
 

HMS, a Gainwell Technologies Company, delivers healthcare technology and analytics solutions to reduce costs and make healthcare work better for payers, providers and members. Our first-in-class coordination of benefits and payment integrity solutions help our nation’s safety net programs save billions annually and ensure sustainability. Visit https://discover.hms.com/health-ideas to learn more.