Federal Audits and Enforcement of Telehealth Providers: Future Trends and Risk Mitigation | Goodwin


As the COVID-19 pandemic progresses and increased telehealth use appears to level off over the past year, according to a July report from McKinsey & Company, federal agencies have continued the trend. recent enforcement actions and audits of telehealth providers.

On September 17, 2021, the Office of the Inspector General of the United States Department of Health and Human Services (HHS OIG) and the United States Department of Justice (DOJ) announced their latest enforcement action, totaling $ 1 , $ 4 billion, of which approximately $ 1.1 billion involved suspected telehealth fraud. This is the latest action taken by law enforcement agencies, with $ 143 million in COVID-19 law enforcement action announced in May 2021 and law enforcement action on the $ 4.5 billion telehealth announced in September 2020. These actions have focused in part on the use of telehealth to submit fraudulent claims. private payers as well as federal health care programs. The May 2021 coercive action involved fourteen defendants in seven federal judicial districts and the September 2020 enforcement action involved more than three hundred defendants in fifty-one federal judicial districts.

This latest round of coercive measures from September 2021 targeted telemedicine executives who allegedly paid doctors to nurse practitioners in exchange for ordering durable medical equipment, genetic testing, other diagnostic tests and pain relievers deemed unnecessary. . The government blamed the items that were ordered with no patient interaction or minimal phone conversations, and the doctors and nurse practitioners in question had never even met or seen their patients. Additionally, in January 2021, the HHS OIG announced a series of audits examining Medicare Part B payments to telehealth providers during the public health emergency to determine whether Medicare requirements were being met. The first phase of audits focuses on whether services such as assessment and management, opioid use disorders, end-stage kidney disease, and psychotherapy meet Medicare requirements. The second phase includes additional audits of remote and originating site locations, virtual registration services, electronic visits, remote patient monitoring, use of telehealth technology, and annual property visits. -to be.

Although the long-term effects of the actions of federal agencies remain unclear, as long as telehealth is used at a substantial level, government agencies are likely to continue to review the practices of the telehealth industry to mitigate fraud, waste and abuse. Telehealth providers and other industry players can reduce the likelihood and impact of being audited or charged as part of an enforcement action by structuring their compliance programs and operations to comply with federal health care program requirements, such as provider accreditation, sufficient documentation of medical needs, program integrity requirements, and other coverage and reimbursement issues.

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