How To Avoid Telehealth Fraud

Telehealth has been known as a potentially transformative new technology for years. The ability to provide remote medical care via technological channels gives much-needed access to health resources for patients in rural areas or who have difficulty traveling to their providers. 

However, it didn’t really take off until the COVID-19 public health crisis made the adoption of telehealth a necessity. Telehealth usage grew by 78 times between February 2020 and April 2020. While usage declined from that peak, in February 2021 visits were still 38 times more than the same point in 2020, and continues to be popular even in 2022. Telehealth is undeniably here to stay, even now that the pandemic has largely subsided. 

However, new technologies bring new issues. Medical billing and coding is already a tremendously complex endeavor, and telehealth’s sudden growth added yet another variable to the equation, creating new opportunities for error. And, as is human nature, opportunists continue to find new opportunities for fraud in the rapidly changing environment. How can healthcare providers avoid telehealth fraud? Let’s take a look.

Telehealth Basics

Telehealth is a term for providing healthcare services remotely via telecommunications technologies such as video conferencing, remote monitoring, and web portals. It provides a capacity for clinicians and health workers to meet with patients anywhere they have a secure internet connection, allowing long-distance care, intervention, and other medical consultation. The field continues to evolve, with possibilities such as surgeons being able to perform surgeries remotely using robotics. 

Telehealth has been developing as a field for years alongside the widespread adoption of high-speed internet. However, faced with a nationwide lockdown at the beginning of the 2020 COVID-19 public health crisis, government regulations relating to telehealth were waived or suspended, leading to an exponential increase in the use of telehealth services. Many of these regulatory changes have now been made permanent, and 40 percent of consumers believe they’ll continue to rely on telehealth going forward even after the pandemic. 

New Exposure To Fraud

On 13 March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded Medicare telehealth access, allowing all beneficiaries to receive telehealth in all locations. Private payers and insurers largely followed suit. While the Department of Justice (DOJ), the Office of the Inspector General for the Department of Health and Human Services (HHS-OIG), and CMS are increasing scrutiny of telehealth providers and services as telehealth becomes more common, their enforcement actions are largely centered on government programs such as Medicare and Medicaid. Healthcare payers of all types must step up their payment integrity programs to address telehealth fraud. 

Fraud, waste, and abuse costs take a variety of forms, from medical coding inaccuracies to complex, multi-entity kickback schemes. Government agencies have been able to use claims analysis and advanced data analytics to recognize emerging patterns and ferret out complex fraud schemes that in prior years might have escaped notice due to crossing jurisdictional lines. While this type of approach works best at scale, all healthcare payers can use the same techniques to detect and prevent fraud, waste, and abuse costs on medical claims. 

Telehealth And Compliance: Technological Solutions 

The government has been using data analytics to detect healthcare fraud, waste, and abuse through data analytics through the Medicare Fraud Strike Force, with impressive results. 

Our sophisticated data analytics allow us to identify patterns across different types of health care providers—giving us a way to identify trends and extreme outliers,” said Brian Boynton, Acting Assistant Attorney General, at a Federal Bar Association conference. “We can see where the highest risk physicians are located in each state and federal district, and how much they are costing the Medicare program. The data can even allow us to demonstrate and quantify sophisticated relationships, such as a physician offering controlled substance prescriptions to a patient who is likely to divert them. Identifying these types of relationships can help us combat prescription drug abuse as well as many other types of health care fraud.”

The next frontier is artificial intelligence; HHS and CMS both include AI in their strategies for combating F,W&A costs in the future, using the technology to derive data-driven insights and identify potential fraud.

Partnering With Technological Innovators

These capabilities can be expensive for non-governmental healthcare payers, as they work best on a large scale. However, one option for healthcare payers to leverage the same tools as HHS or CMS and avoid telehealth-related fraud, waste, and abuse charges is to partner with a payment integrity specialist such as Alaffia Health. 

While government agencies are still developing AI-based solutions, Alaffia Health’s advanced AI platform is already working to protect our partners from F,W&A charges. Our system integrates with our partners’ software to identify high-cost medical claims with a high probability of containing overbilling. Our innovative use of these emerging technologies allows us to review more claims and save our partners more money.

Utilize the technology government agencies will be using tomorrow, immediately. Alaffia Health brings an innovative, turnkey solution to the table. Find out how today.