In response to the growing need for telehealth, the Department of Health and Human Services issued a waiver on March 6, 2020, allowing all Medicare beneficiaries in all areas of the country to receive telehealth services from home. Previously, telehealth was only allowed in rural areas from healthcare sites. The waiver relaxes several other regulatory guidelines including those surrounding HIPAA, copays, deductibles, and more.
While telehealth has become a lifeline during the pandemic, the potential for improper coding and documentation—and fraud, waste, and abuse—is high. Until reimbursement for telehealth is better understood, health plans are wise to include telehealth claims in their clinical audit programs.
New telehealth regulations
As they manage telehealth claims, health plans need to first fully understand the new payment requirements. There are three types of telehealth services that fall under the telehealth expansion waiver:
- Medicare telehealth visits are visits with a provider via telecommunication systems that offer audio and video
- Virtual check-ins are brief, patient-initiated check-ins with providers via telephone or other device to determine whether an office visit or other service is needed
- E-visits cover communications between a patient and provider through an online patient portal
The waiver also includes stipulations as to whether the patient must be an established patient. A range of providers including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers can offer telehealth services. In its fact sheet, CMS provides greater detail, as well as HCPCS and CPT codes for telehealth services.
Telehealth payment risks
Relaxing telehealth regulatory guidelines has led to growing concern about a potentially heightened risk of improper payments. Concern has arisen around a few factors:
- CMS has approved 135 additional temporary billing codes for telehealth services, and new information and guidelines are changing by the minute, causing confusion and raising the risk of error
- Penalties for some HIPAA violations may be waived to encourage telehealth, though this raises concern for patient privacy and safety
- States and the federal government have loosened state licensing restrictions, allowing providers to work across state lines, widening the potential for liability and malpractice repercussions
- States like California have their own telehealth regulations, which are stricter than the federal government’s. These state regulations must take precedence
Telehealth in clinical audits
As telehealth continues to skyrocket and with relaxed guidelines, health plans need to begin including telehealth claims in their clinical audit programs. Claims need to be reviewed for legitimacy to spot instances of fraud. Plans need to validate that services are coded and billed correctly and verify that appropriate documentation is included in all claims.
Telehealth has been making great inroads in helping to combat the COVID-19 crisis, but until it is better understood, health plans are wise to approach this uncharted territory with a dose of caution.