Posted and filed under Compliance, FWA, Medical Record Auditing, Payers.

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Every day, we read another article or another news release about the ever-changing world of telemedicine and reimbursement opportunities.  It still stands to reason that even though there are now more opportunities for providers to continue operations by providing services and continuity of care for patients, treating new patients, and keeping their lights on, none of the changes allow for fraud, waste or abuse to be part of that calculus. 

We have fielded many calls regarding documentation requirements as part of the expanded world of telemedicine we are currently living in.  As a CMS Administrator recently indicated; telemedicine is essentially here to stay.  That being said, providers absolutely need to ensure that they are meeting the requirements for documentation.  The mere fact that a patient is not physically in front of you, and the ability to document the encounter may be a bit more challenging, does not in any way absolve the provider from that documentation responsibility.

I have begun to discuss the fact that providers absolutely need to document the treatment, and code to the treatment document.  In too many instances, providers are coding to the treatment, regardless of the documentation.  In an audit, regardless of COVID-19 (of course, I have to mention COVID-19 in anything that is published these days), documentation will drive a provider’s ability to adequately pass an audit. 

Make no bones about it, audits for documentation supporting the telemedicine Evaluation and Management encounter WILL happen. It is only a matter of when. Data analytics will identify the outliers.  Data analytics will drive who gets audited.  Providers may see an audit come to them years from now.  Overpayments will be massive, due to the amount of money being paid out for these services. 

General Evaluation and Management audits have always been on payers’ radars, and the telemedicine audits are going to be no different.  Big money is being paid out, and big money will be sought for poor documentation.  It is not always a matter of fraud, waste and abuse.  Sometimes it is from poor internal compliance with identifying lapses in documentation.  If you fix it now, you can be better positioned in the future to ensure that a huge overpayment is not assessed. 

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.