Telehealth Billing Largely Met Medicare Requirements During Pandemic

February 21, 2024 - Healthcare providers met Medicare requirements when billing for most evaluation and management (E/M) services provided via telehealth, a new federal report shows.

Released this month by the Department of Health and Human Services (HHS) Office of the Inspector General (OIG), the report aimed to determine whether physicians and other healthcare practitioners using telehealth to provide E/M services complied with Medicare requirements.

In March 2020, as COVID-19 cases began to soar across the United States, Congress and the HHS secretary authorized the Centers for Medicare & Medicaid Services (CMS) to enact temporary waivers to expand access to healthcare under the Medicare program. These waivers allowed Medicare beneficiaries to receive various healthcare services via telehealth, including E/M services.

E/M services skyrocketed during the COVID-19 pandemic, with Medicare Part B paying approximately $10.3 billion for these services, including those provided via telehealth in the first nine months. This prompted the OIG to conduct a nationwide audit to assess compliance with Medicare telehealth requirements.

The agency examined $1.4 billion in Medicare Part B payments for more than 19 million E/M claim lines of services between March 2020 and November 2020, billed with codes or modifiers indicating telehealth use. The auditors selected a random sample that consisted of one set of 30 E/M services billed as telehealth services provided to new patients and two sets of 40 billed as telehealth E/M services provided to established patients.

Of the 110 E/M services studied, the auditors found that healthcare providers complied with Medicare requirements for 105 services.

Providers did not comply with Medicare requirements for the remaining five E/M services studies, either not documenting or insufficiently documenting the services. As a result, Medicare paid $446 for the services.

“This report does not have recommendations because providers generally met Medicare requirements when billing for E/M services provided via telehealth and unallowable payments we identified resulted primarily from clerical errors or the inability to access records,” the auditors concluded.

The report aligns with prior OIG audits on telehealth billing.

A report released in September 2022 showed that only a small portion of providers billing for telehealth posed a high risk to the Medicare program.

For the audit, the OIG reviewed Medicare fee-for-service claims and Medicare Advantage encounter data, finding that about 28 million Medicare beneficiaries (40 percent) used telehealth from March 1, 2020, to Feb. 28, 2021. They also found that approximately 742,000 providers billed for a telehealth service.

Of the 742,000 providers billing for telehealth, 1,714 providers engaged in billing that posed a high risk to Medicare. The high-risk billers received a total of $127.7 million in fee-for-service payments.

Further, more than half of the 1,714 providers worked in the same medical practice as at least one other provider whose billing posed a high risk to Medicare, which "may indicate that certain practices are encouraging such billing among their associated providers," the report noted.

Last year, the HHS-OIG released a toolkit to help healthcare stakeholders, including Medicare Advantage plan sponsors, private health plans, and State Medicaid Fraud Control Units, analyze their telehealth claims data to assess program integrity risks.

The toolkit details five steps stakeholders should take when analyzing telehealth claims, such as conducting quality assurance checks on the data and using data analytics to determine program integrity risks. It also provides seven measures that stakeholders can use to analyze claims data, including measures that identify providers who bill for telehealth services at the highest, most expensive level every time and providers who bill for a high number of unique patients.