Amidst concerns that current levels of telemedicine reimbursement are insufficient to support the demand for telemedicine visits, a 2018 report by the Department of Health and Human Services Office of Inspector General (OIG) reveals that a significant portion of the Medicare telemedicine payments that have occurred were actually improper; they never should have been approved in the first place. The overpayments amounted to roughly $3.7 million—a sizable chunk of the total $13.8 million in payments that Medicare made in 2014 and 2015. The reasons for the disallowed claims were numerous and varied.
The OIG examined 191,118 telemedicine claims from 2014 and 2015. A random sample of 100 claims was scrutinized further; of these, 31 should have been disqualified for failure to meet Medicare requirements for reasons including:
- The patients received services at originating sites that were not classed as being “rural.” Out of the 31 disallowed claims, 24 fell into this category.
- The institutional provider at the distant site—such as a critical access hospital (CAH)—was ineligible for reimbursement. To be authorized for payment, the distant provider must have already made certain designations.
- The originating site was unauthorized; the Federal regulations specifically enumerate the type of sites that are allowed. This includes, among others: a practitioner’s office, a hospital, a CAH, a rural health clinic, a skilled nursing facility, or other facilities not mentioned in this article for brevity.
- The form of communication utilized was ineligible for reimbursement; instead of an interactive telecommunications system, either telephone, email, or fax was used.
- The claim was filed for a non-covered service.
- The service was provided by a physician located outside the US; under the regulations, the services must be provided within US borders in order to be eligible for reimbursement.
Upon investigation, it was discovered that the telemedicine reimbursement claim forms do not have specific fields for the geographical location of the originating site or for the form of communication used by the practitioner; according to Centers for Medicare & Medicaid Services (CMS) officials, this detail is by design because non-telemedicine practitioners use the same claim form. Thus, with no applicable form fields, it becomes harder for Medicare Administrative Contractors (MACs) to catch such inaccuracies, nor can they edit forms as necessary.
To reduce the incidence of similar oversights in the future, the OIG recommended that the CMS implement these actions:
- Periodically conduct post-payment reviews for errors
- Work with MACs to edit claim forms more accurately
- Educate and train providers specifically on Medicare telemedicine requirements
So far, no enforcement actions have been taken, but whistleblowers could file complaints under the False Claims Act. To minimize this possibility, practitioners and stakeholders should familiarize themselves with Medicare telemedicine reimbursement requirements, especially considering the upcoming changes resulting from the passage of the Increasing Telehealth Access to Medicare Act and other legislation earlier this year.
To view the OIG report, click here.