Posted and filed under Fraud, FWA, Healthcare.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

Under Medicare rules, telemedicine, or telehealth as it is also commonly known, required a very specific set of circumstances for a provider to be paid.  With Coronavirus (COVID-19) being at the top of mind, how the Center for Medicare and Medicaid Services (CMS) chose to make a regulatory change on the fly should be an extremely commendable act.  As we in the healthcare payment integrity world know, CMS is often slow to issue rules and opinions that are behind the technology and practice curve.

Under CMS guidelines, prior to Coronavirus, a very narrow set of circumstances would have to exist for a telehealth service to be a reimbursable event.  CMS, however, has readily identified that we are currently working under healthcare payment integrity “battlefield conditions.”  Due to the unprecedented nature of what is currently happening, it is imperative to deploy healthcare resources in a manner that protects the Medicare population, as well as affording those providing that protection, the greatest latitude in such care.

The current CMS rule allows healthcare providers the flexibility to submit claims for reimbursement with much fewer restrictions.  Just as important, the OIG stepped in and added that it will not seek to investigate those instances where providers waiver cost-sharing responsibilities of Medicare beneficiaries, also known as the co-payment.  Under any normal circumstance, the waiver of a co-payment is considered a kickback, and exposes a provider to criminal, civil and administrative actions.

These two steps taken together really do help to move the healthcare ball forward.  In any other circumstance, I am sure payment integrity, fraud, waste and abuse investigators would be rolling over cringing at the thought of waiving co-payments and blanket changes to the regulatory landscape overnight.  We are, as everyone knows, not working within the traditional fraud, waste and abuse atmosphere.

Just as important to the two items above, was the additional step of allowing providers who would otherwise not be able to submit claims for reimbursement due to not being participating providers, to treat and seek reimbursement for such treatment.  Of course, all these measures are temporary.  Once the dust settles on this virus, CMS will hopefully seek to make sweeping changes in its current position on telehealth and open the potential range of care opportunities to the Medicare population.

As with every national and international emergency, we will all get through this.  As soon as I am done typing, I will be washing my hands—again.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.