Problematic Telehealth Claims

Ten years ago, telehealth and telemedicine barely existed. Sure, you might have gotten a call from your doctor or pharmacist for small things, but as far as healthcare is concerned, most visits were completed in-office.

Telehealth has taken the world by storm in recent years, providing access to healthcare even for remote patient populations. The problem is that now, a small percentage of those telehealth and telemedicine claims are posing a risk to Medicare.

In this blog, we’ll explore the rise of telehealth, why some telehealth claims are problematic, and how we can help solve this problem.

The Rise of Telehealth

We have never seen a catalyst for digital innovation stronger than the pandemic. As the world went into lockdown and many were terrified of leaving their homes, let alone visiting their doctors, a need arose for a different kind of healthcare.

Enter, telehealth. Telehealth made it so patients could still see their doctors without ever having to leave their homes. In addition to this, it gave patients access to doctors who may be located outside of their town or city.

With innovation comes obstacles. Although telemedicine gave patients access to the care they needed at the press of a button or swipe of screen, this introduced a new challenge for healthcare systems and payers: telehealth claims and the quality of care delivered.

What is happening with telehealth claims?

Fast forward to 2022, and we’re beginning to see problematic claims that pose a risk to Medicare. The Office of the Inspector General conducted a study that focused on 742,000 service providers who billed for a telehealth service. They identified 1,714 providers whose billing for those services indicated fraud, waste, or abuse. These providers are responsible for billing telehealth services for about half a million members, and they received a total of $127.7 million in Medicare fee-for-service payments. These fraudulent claims have an immediate impact and may also cause future disruptions by increasing the cost of care and scrambling telehealth claims data for future years.

Solving the CMS Telehealth Problem

The OIG report offered a few recommendations that CMS could follow to help minimize the risk. Here are some of their recommendations:

The first step to overcoming the CMS telehealth problem is to identify telehealth companies that bill Medicare. This gives CMS a virtual roster of the providers that are utilizing that telehealth service and can help cast a smaller net.

CMS should strengthen monitoring and targeted oversight of telehealth services to ensure that providers are not inappropriately billing, or billing for “incident to” services.

O1G also recommended that CMS follow up with the providers that filed those problematic claims, which CMS has already acknowledged that it would do.

Can Robotic Process Automation Help?

The rise of digital healthcare services means that payers need to embrace technology in order to keep up with the pace of change.

While there isn’t a one size fits all solution to the telehealth claims problem, there is one thing that health plans can do to weather the storm.

SymKey is a robotic process automation solution that helps health plans process healthcare claims more efficiently. RPA can help payers recognize errors and identify red flags without overwhelming staff or overburdening maxed out examiners.

HCIM has been a trusted partner in the industry for over two decades, applying innovative technology to help automate business processes. Our team of industry experts help organizations reduce costs and increase revenue, allowing staff to focus on more complex tasks.

For more information on how we can help you turn complexity into simplicity, contact us to speak with one of our experts today.