OIG Unveils Telehealth Toolkit to Analyze Program Integrity Risks

By: Jim Hoover, Burr & Forman, LLP

Over the course of the last year, audits of telehealth services and the associated claims data has continued to increase.  As a result, it may be useful for physician practices to conduct a compliance review of the telehealth claims they submitted since the beginning of the COVID-19 pandemic.  Of course with any compliance audit, healthcare providers should think carefully about the manner and procedures used in an audit.

A useful source of information related to telehealth claims is the OIG’s telehealth toolkit.  On April 20, 2023, the Office of Inspector General (OIG) unveiled a new telehealth toolkit designed to help identify program integrity risks associated with telehealth services.  A copy of the toolkit is located here. The toolkit provides detailed information on methods to analyze telehealth claims to identify program integrity risks. While the OIG created the toolkit to assist public and private sector partners such as Medicare Advantage plan sponsors, private health plans, State Medicaid Fraud Control Units, and other Federal health care agencies with analyzing their telehealth claims data, it can also be used by physician practices to review their telehealth claims.

The OIG created the toolkit because the COVID-19 pandemic changed how patients visit and interact with their health care providers. The use of telehealth services grew dramatically during the first year of the pandemic and is now an important part of the health care system. For example, Medicare beneficiaries used 88 times more telehealth services during the first year of the pandemic than in the year prior, with more than 2 in 5 Medicare beneficiaries using telehealth services in that year. Medicaid and private health plans also experienced exponential growth in the use of telehealth. With the dramatic increase of telehealth visits, came concerns about fraud, waste and abuse associated with the use of telehealth.  

The toolkit includes detailed descriptions of seven data analysis measures providers can apply to their own data.  The toolkit also includes steps for analyzing telehealth claims such as (1) reviewing program policies, (2) collecting claims data, (3) conducting quality assurance checks, (4) analyzing data to identify program integrity risks, and (5) interpreting the results of the analysis. When beginning the analysis process, it is important to be familiar with payment and coverage policies of the particular program being reviewed, such as traditional Medicare or a commercial payor.  The toolkit is based on Medicare fee-for-service payment and coverage policies for telehealth services during the first year of the COVID-19 pandemic (March 2020 through February 2021).  Be aware that Medicare telehealth policies changed over time and different programs may have different policies.  As a result, the analysis of the telehealth claims will vary according to the coverage and billing policies of a particular program and for the particular time period.  During the COVID-19 pandemic, Medicare claims for telehealth services used a modifier of 95, GQ, or G0 or a place of service code of 02 to indicate that the service was delivered via telehealth.  The Centers for Medicare & Medicaid Service’s website also maintains a complete list of services that may be provided using telehealth under Medicare.

The measures in the toolkit are intended to be a starting point for the analysis of telehealth claims and are based on patterns in the Medicare claims data during the first year of the COVID-19 pandemic. Billing patterns in other data may be different from those in Medicare data, so it may be necessary to adjust the analysis accordingly. For example, the OIG considered providers who billed telehealth services for 2,000 or more Medicare beneficiaries during a year to be high risk. This number is far higher than the median of 21 Medicare beneficiaries. 

The toolkit contains seven measures the OIG developed to focus on different types of billing for telehealth services.  Some the measures include billing telehealth services at the highest most expensive level for a high proportion of the services billed, billing a high average number of hours of telehealth services per visit and billing telehealth services for a high number of days in a year or a high number of patients.  

Although the OIG designed the toolkit to analyze program integrity risks, it is a useful resource for physician practices to help them understand the particular areas of concern of the OIG.  It provides easy to understand analysis of claims and thresholds the OIG considers to indicate a high risk of fraud, waste or abuse.   

Jim Hoover is a Partner at Burr & Forman LLP practicing exclusively in the firm’s healthcare group. Jim may be reached at (205) 458-5111 or jhoover@burr.com.