Overbilled? Texas watching for ‘suspicious activity’ with the rise of telemedicine

Simple Health

AUSTIN (KXAN) — Throughout the pandemic, demand for telemedicine and virtual healthcare services has skyrocketed, putting state health officials on high alert for improper billing and even fraud.

According to a report from the Office of the Inspector General — which oversees the Texas Health and Human Services Commission — the spread of COVID-19 prompted changes that eased technology restrictions and expanded the number of Medicaid services available through telehealth and online options.

In 2019, provider reimbursement for telemedicine and telehealth services averaged less than $800,000 per month, but reimbursements jumped to $9 million in March 2020 and $43 million by April 2020, according to the OIG report. Reimbursements for telehealth averaged more than $37 million monthly throughout 2020.

While the shift to virtual services may have helped these patients stay safe in their homes and still receive medical care, the report notes that it may indicate “wasteful errors or possible suspicious activity” when it comes to billing for these services.

The report focused on certain billing patterns involving telephone-only services or multiple services in a brief time frame, such as:

  • Physicians calling patients as a “follow-up” within the same week as a telemedicine visit
    and billing an evaluation and management (E&M) code.
  • Physicians performing telemedicine visits, then an in-person visit, with a modifier
  • Physicians calling patients they had not recently seen and who had not requested an appointment to “check up” on them and billing an E&M code.

The report also stated that telemedicine can become “vulnerable to overbilling” when providers bill for “impossible hours” for a 24-hour day.

“There are situations in which telehealth services are billed more than 24 hours by a single provider, due to services being rendered by assistants. If this is the case, it is taken into consideration,” the report explained.

The OIG report characterized these patterns as “new program integrity issues” they will continue to explore “especially in services where telehealth was not previously used.”

“I’m not going to lie: to see that they were investigating people who were fraudulently using telehealth was extremely disheartening,” said Dr. Suneet Singh, Medical Director for CareHive. “We want to pick out the rotten eggs, the bad apples and we want them out.”

“It’s sickening to be very honest with you.”

Dr. Suneet Singh, Medical Director for CareHive

Using artificial intelligence-powered technology, the clinicians at CareHive partner with medical groups and healthcare systems to provide digital care options.

Dr. Singh calls it the “digital front door.”

“We’re able to help navigate: ‘Oh, well, this facility is closest to you, but you know what? This one is actually a little bit further, but they’re open for you; they work with your insurance plan; they’re still the most cost efficient option,” he said.

He emphasized their goal was to keep healthcare options cost-effective for patients and providers.

“You know, it’s always easiest to do the most expensive thing, but that’s not the right thing. So, for instance, if you need to talk about your migraine headaches? You want to talk about the results of an X ray? I don’t necessarily need to do an in-person — a touching a physical encounter examination — because that’s a conversation. So, we navigate the patient to the right modality,” he explained.

After reviewing the OIG report, Dr. Singh still said he thinks — on the whole — the problems in the report most likely stem from physicians misunderstanding the billing codes and procedures.

Experts with the Texas Medical Association, agreed, saying they weren’t concerned about the patterns highlighted.

“This is a natural evolution of anything new,” said Dr. Ogechika Alozie, a member of TMA’s COVID-19 Task Force.

“There’s a period of understanding where the insurer is trying to understand, the physician is trying to understand.”

Dr. Ogechika Alozie, Texas Medical Association

He encouraged physicians to utilize the resources on TMA’s website to educate themselves and encouraged patients to take an active role in learning about the process.

“Talk to you insurer, and feel free to talk to your physician,” Alozie said. “‘What does this visit entail? How long is it going to be? How much am I going to be charged for this? Is there a co-pay?’ These are the questions every patient should have, whether it is telemedicine or in-person.”

He said TMA was also researching whether billing for in-person visits decreased as much as telehealth services increased. Still, he doesn’t want the results of the report to hinder the growth of virtual health options.

“These are going to be things people need, not only today, but into the future, as health care evolves,” said Alozie.

Copyright 2021 Nexstar Media Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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