Malicious or Misguided – The Importance of Proper Payment Submission

As the COVID-19 pandemic continues to wreak havoc on the American healthcare system, it only makes sense that our providers adapt their practices to service our communities. With state-mandated quarantines, patients who are unwilling, or in some cases, unable to physically visit their doctor in the office, telehealth services are increasingly being utilized to provide care. While this is excellent news for our Medicare population, some fear that the additional telehealth benefits and flexibility will open the door for increased fraud and abuse.

This fear is not unwarranted. For example, last year, the US dealt with a telehealth fraud issue when the owner and CEO of Video Doctor Network plead guilty to fraud in the amount of $424 million; however, not all inappropriate use of telehealth service stems from malicious intent. A great deal of the false claims submitted can be expected to come from providers who simply do not know how to accurately and appropriately record telehealth services. In 2018 alone, Medicare recorded an Improper Payment Rate of 8.1% or $31.6 BILLION dollars that were lost due to preventable billing mistakes. In 6 short years, between 2013 – 2018, there was over $230 billion lost due to improper payment.

Accurate claim submission saves the taxpayers money and ensures appropriate and accurate payment to providers for services rendered. I was speaking with Salient’s Chief Medical Officer, Dr. Craigan Gray, about the issue when he made a great point: “proper billing not only helps the provider collect correct compensation, it also helps prevent penalties for over billing. The government or any insurer will never complain if a practice charges an incorrect lower amount; however, over billing will always be a problem.”

Below are a few resources on coding and billing for telehealth services:

  1. Medicare Learning Network – Telehealth Services Fact Sheet

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

2. Covered Telehealth Services

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

3. Medicare Telemedicine Health Care Provider Fact Sheet

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

4. General Provider Telehealth and Telemedicine Tool Kit

https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf

5. Practice Guidelines for Video-Based Online Mental Health Services

https://www.integration.samhsa.gov/operations-administration/practice-guidelines-for-video-based-online-mental-health-services_ATA_5_29_13.pdf

When we look at the numbers, it’s clear that while we can worry about the potential abuse of needed telehealth services, we are better off focusing our attention on making sure doctors have the training and resources they need to accurately submit payment for their services. Teleservices are here to stay, and if given the right support, the medical community is going to find this additional flexibility an invaluable asset when it comes to connecting with their most remote and vulnerable populations.

References:

https://www.beckershospitalreview.com/healthcare-information-technology/managing-fraud-waste-and-abuse-during-the-expansion-of-telehealth.html

http://medicareintegrity.org/error-rate-drops-but-medicare-still-lost-31-6-billion-to-preventable-billing-errors-in-fy2018/

Stephanie Rotolo

About the Author


Stephanie Rotolo

Stephanie Rotolo is a Business Consultant at Salient Healthcare where she focuses on helping value-based organizations achieve greater success. Her extensive training experience has enabled many Salient clients to better maximize the value of the Salient Healthcare Solution. Stephanie also assists in sales, contracting, marketing, and supporting the entire business consulting team on both the Medicare and Medicaid units.

Prior to her current role, Stephanie worked as a trainer supporting a variety of clients including The Office of Medicaid Inspector General (OMIG), The Office of Health Insurance Programs (OHIP), and New York State Performing Provider System (PPS) analysts as they implemented the NYS DSRIP Program. Stephanie graduated from the State University of New York at Albany with a bachelor’s degree in economics.

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