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Telemedicine Audit Findings

April 21, 2020
Documentation, Billing, & Coding By Deborah Alexander, Director

Recently, the Office of the Inspector General (OIG) and National Government Services (NGS) released findings and claims submission errors for billing for Telehealth services. In the past weeks, the Coronavirus (COVID-19) pandemic and declared public health emergency (PHE) has forced many providers to quickly convert to providing Telemedicine, Telehealth and eHealth without fully understanding the regulations in an everchanging environment.

 

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Although the Centers for Medicare & Medicaid Services (CMS) and private payers have expanded telehealth coverage to previously excluded providers during the PHE, not all have consistently implemented the guidance they provided. So, even during the PHE, it is important for compliance professionals and owners to be aware of the common errors reported by various agencies. When the PHE is removed, many regulations will return to the prior conditions of participation and payment, thus being prepared to audit telemedicine in the future will be a risk.

Below, we will discuss a few audits released in the recent weeks.

OIG Telehealth Audit Report South Carolina

On April 16, 2020, the US Department of Health and Human Services (HHS) and Office of the Inspector General (OIG) released several reports and enforcement actions. The OIG reported Ninety-six (96) percent of South Carolina’s Medicaid Fee-for-Service Telemedicine payments were insufficiently documented or otherwise were not allowable. The purpose of this audit was to determine whether payment telemedicine services met Federal and State payment regulations.

How Did the OIG Conduct the Audit and What Were the Findings?

A stratified random sample of 100 payments totaling $27,470 ($19,608 Federal Share) were selected from South Carolina claims with dated ranging from July 1, 2014 to June 30, 2017. The audit period covered $2.3 million in payments ($1.6 million Federal share) for “telemedicine services” only. The OIG recommended South Carolina pay the Federal government back $1.5 million dollars which is the estimated unallowable Federal Share for the claims submitted during the audit review period.

The OIG audit findings noted 97 unallowable payments with the following errors:

  • Due to a lack of documented start and stop times and not containing the proper consulting location of the service, 95 were not allowable.
  • Two were not allowable as the services were actually provided for in-office consultations, which is not telemedicine
  • The report documented the noncompliance occurred due to a lack of training provided by South Carolina on providing telemedicine documentation requirements or adequately monitoring the compliance.

The findings of this report can be found here.

National Government Services (NGS)

On April 15, 2020, NGS released an email to subscribers entitled, “Proper Billing for Telehealth Services Claims”. NGS notified providers that a high volume of CMS-1500 paper claims forms were being received during the PHE and were being rejected due to the incorrect place of service (POS) being applied to claim. Here is what NGS released:

“We have received a high volume of paper CMS-1500 claim forms for telehealth services with dates of service during the public health emergency (PHE) that we have to reject because they are improperly coded with two different place of service (POS) codes on one claim (example 11-office, 02-telehealth).

The CMS-1500 paper claim form cannot contain more than one POS. This rule does not apply to electronic (837) claims.

The PHE is effective for services performed on and after 3/1/2020. At this time, there is no end date to the PHE.

If you are offering telehealth services as part of the PHE, those claims should be submitted with the POS from where the face-to-face service is normally performed (e.g., office POS 11, hospital POS 21) and include modifier 95 to identify this as a telehealth service during the PHE; this is the preferred method for submission.

If you are offering telehealth services as you would under normal circumstances, you may continue to bill your POS as 02 and include modifier 95 to identify that the service was provided during the PHE; which will be paid at the facility fee schedule rate.”

What to Consider?

As the PHE remains in place and telemedicine expands, both providers and patients are realizing substantial benefits for many patient conditions.  Preparing for healthcare services to continue in a virtual manner after the PHE is a real consideration for many providers. Incorporating telemedicine services into your audit planning poses challenges. Telehealth audits are not your typical audit protocols and may actually include audit log trails for location service verifications. Typically, Information Systems (IS) may not be part of your defense to an adverse telemedicine audit by a payer, but having IS involved going forward will be a critical consideration for verifying a provider and/or patients location when telemedicine services are provided.

LW Consulting, Inc. has experts who assist clients  by providing guidance on establishing telemedicine auditing protocols.  We can provide information on how to integrate telemedicine services and payment into your audit plan. We can also conduct the audits with protocols that utilize the guidance in place at the time the services were rendered. 

 

For more information, contact Deborah Alexander at 717-213-3122 or email DAlexander@LW-Consult.com.

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