As healthcare spending continues to rise, so too does the inherent risk for bad actors to take advantage. Today, the United States is estimated to spend nearly 18 percent of its GDP, or $3.6 trillion, on healthcare, and is expected to increase to one-fifth of GDP within the next decade, according to the latest data. This alone provides ample motivation for fraud and abuse. While the full extent of healthcare fraud is difficult to measure,
The National Health Care Anti-Fraud Association (NHCAA) conservatively estimates that 3 percent – $68 billion – of all healthcare spending is lost to fraud each year. Others, such as the Federal Bureau of Investigation (FBI), estimate fraud accounts for up to 10 percent of healthcare expenditures.
Unfortunately, the COVID-19 pandemic has only accelerated the motivation for fraud and abuse amid the increased fear, confusion, and a relaxed regulatory environment. From fake cures to malware and illegitimate charities, fraudsters are taking advantage. Telehealth, which has experienced exponential growth aided by regulatory accommodations to facilitate its widespread adoption, is an area of particular concern. In turn, states and healthcare organizations must optimize their program integrity operations and telehealth strategy to stay protected amid healthcare’s new normal.
Greater Access Brings Greater Risk
The pandemic-driven expansion of telehealth has been profound in terms of enabling care access and continuity while reducing the risk of infection. When the Centers for Medicare and Medicaid Services (CMS) temporarily expanded telehealth coverage at the start of the pandemic, adoption soared to unprecedented levels.
According to a McKinsey report, providers have seen 50 to 175 times more patients through telehealth appointments compared to any year prior. At the same time, once-strict regulations governing telehealth services have been relaxed during the COVID-19 emergency, and the federal government has proposed to make permanent many of the regulatory changes initially meant to temporarily increase access to telehealth.
In parallel and perhaps unsurprisingly, there is a growing sentiment that telehealth is here to stay. According to a recent CynergisTek survey, 70 percent of consumers plan to continue using telehealth post-pandemic. From a provider perspective, new research from Bain & Company found that more than 80 percent of providers will continue to use telehealth as much or more than they do now.
All this considered, we must acknowledge the inherent risks of this technology. Telehealth has a poor track record for fraud, waste and abuse, with some of the largest healthcare fraud schemes involving telehealth providers. This September, for example, the Department of Justice announced the largest case of healthcare fraud in history, involving more than 300 individuals who submitted over $6 billion in fraudulent claims, with telehealth accounting for $4.5 billion of those claims.
With providers struggling to meet fluctuating demand amid unprecedented revenue shortfalls, improper billing practices — both intentional and inadvertent — are, to some degree, inevitable. Factor in hundreds of new telehealth codes and coding considerations as well as the overall stress on the healthcare system, and it is clear we must examine existing risk mitigation measures through a new, post-pandemic lens.
Strategies for Mitigating Telehealth Fraud & Abuse
For healthcare organizations and, specifically, special investigation units (SIUs) tasked with combatting fraud and abuse, the shift to telehealth adds an additional layer of complexity. Fortunately, there are strategies healthcare organizations can implement to successfully navigate the evolving landscape while strengthening the integrity of their operations for healthcare’s new normal.
Data visualization is a key component of an effective fraud investigation. Charts and graphs provide a clear representation of trends and outliers, including connections that could indicate a kickback or collusion scheme. Critical to the success of these tools, however, is the quality of the data that underlies them. Collecting sample data based on the appropriate modifiers and conducting thorough background research provides an accurate portrayal of events from which SIUs can clearly identify and pursue potential fraud schemes.
Integrating qualitative research into telehealth strategies is a great way to capture fraud at the source. When appropriate, conducting interviews with patients can validate whether services were in fact rendered as billed. For instance, a provider may bill for audio-only services as if they were delivered in an audio-visual capacity, resulting in an unjustifiably higher reimbursement rate. Similarly, using data visualization techniques to identify suspect trends, such as blanket billing or an implausibly high volume of services during a known low-demand period, can inform pointed questions for patients.
As we traverse this unprecedented territory, being on high alert for potential indicators of fraud and abuse is critical to protecting healthcare organizations and consumers. If something doesn’t make sense, whether clinically or in the context of the larger healthcare landscape, it is worth investigating. Understanding the limitations of telehealth and other key considerations surrounding its use will help to ensure we are maximizing the benefits of these services while mitigating their inherent risks.
Evolving Together
Healthcare providers and patients alike have embraced telehealth during the COVID-19 crisis and, in doing so, confirmed what advocates have been saying for years — that telehealth promotes greater access to care. While ultimately good news for stakeholders across the healthcare spectrum, the environment we find ourselves in today has also created new avenues for fraudsters to take advantage. As telehealth becomes an inseparable part of the healthcare ecosystem, we are quickly learning how to identify telehealth fraud schemes, and, more importantly, strategies to mitigate the risks they post to integrity and security in the space.
About Gary Call, M.D.
Gary Call, M.D., is senior vice president and Chief Medical Officer at HMS, where he leads the company’s clinical program development and execution. Dr. Call has more than 25 years of experience in the practice of medicine and managed care. Dr. Call graduated from the University of Washington School of Medicine and completed his residency training at the University of Utah. He is a board-certified family physician.
