Posted and filed under Fraud, FWA, Healthcare, Payers.

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.

Although I had strongly thought about not discussing anything COVID-19 related in this week’s blog, the bandwagon is just too big not to continue to ride it.  Every single day there is some new post, guidance, thought or discussion about the newest telehealth and telemedicine rule changes that have come from CMS.  Recently, I posted (not as a blog) on LinkedIn about how I felt that this was a great step, but that the full benefits would be for the next generation, and not the current generation of Medicare beneficiaries.

My thought process is absolutely not empirical and is based solely on my two parents’ technical capabilities.  My parents are both near 80, and although they have attempted to embrace technology, it has been a challenge for them.  This is not to say that there aren’t a great number of technologically savvy Medicare beneficiaries, just that the next generation of beneficiaries will really take advantage of it.

My overall thoughts, however, are on the collateral and ancillary frauds that will result from the relaxed rules.  My thoughts are with schemes that are similar to the now famous “Brace Yourself” investigations.  With the relaxed rules that include FaceTime, Skype, telephone, etc., there really is nothing to stop the telemarketing firm from initiating a call soliciting interest for products, services and items with a doctor on the phone.

What about the hijacking of an NPI by a telemarketing firm and submitting a claim for the virtual visit?  Here is where the problem will be even greater.  With investigations that involved a failure of a doctor-patient relationship to exist, the greatly expanded use of telemedicine will afford unscrupulous providers the opportunity to submit a claim for a visit and establishing a doctor-patient relationship that otherwise did not exist.

Keeping in mind that a fraudulent claim is still fraudulent if it is misrepresented, contains false information, is tainted by a kickback, etc.  it will be a difficult task to conduct the investigative follow up since there will be a deluge of claims for telemedicine and telehealth that were not previously able to be submitted.

I am reminded that there is a difference between telehealth and telemedicine.  Most notably, telehealth involves services that do not necessarily involve a physician rendering a medical determination, in that the remote monitoring of cardiac health, diabetic monitoring, etc. are telehealth and not necessarily telemedicine.

Providers need to ensure the documentation is extremely specific to the service, and date and time stamping will be a great way to enhance internal compliance ensuring there is adequate proof that the service was rendered in the manner in which it was submitted for reimbursement.  From a payor perspective, the analytics will be churning at a rapid pace once everyone wraps their heads around the fraud schemes.  Now may the time to being looking at vendors for overflow and targeted specific audits and reviews to ensure that program integrity mechanisms are continuing to be robust and paid as appropriate.

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.