Government Oversight in Telehealth Initiatives

If you’re in the business of Government-Sponsored Programs (Medicare, Medicaid, ACA), you live in a world of regulatory oversight and seasonal paranoia. The anticipation of being audited looms large, especially as CMS allows for expanded, billable services that increases access to Providers and delivers non-traditional, telehealth or virtual care to patients and members.

While these services are well intentioned and desperately needed, they require significant oversight. Earlier this month, news broke of the $6B fraud cases involving telehealth schemes.

In response, the DOJ is creating a “new rapid response strike force to investigate fraud cases involving major providers that operate in multiple jurisdictions.”

Increased Fraud for telehealth services has been on the rise since 2016, and now that these encounters are deemed acceptable for Risk Adjustment purposes, there is reason for concern at the level of oversight and auditing being performed by Health Plans.

This isn’t just for RADV mitigation and overpayment recovery, but also for Member Experience – the lynchpin to achieving the coveted 5 STAR Rating. As noted in STAR expert Melissa Smith’s recent article, starting in 2021, the critical Member Experience has an increased weight for STAR ratings.

I predict that the Office of Inspector General (OIG) and Department of Justice (DOJ) are going to focus their watchful eyes on these expanded telehealth initiatives.

We should expect a high level of scrutiny, especially for health plans that have managed to maintain or improve Risk Scores despite the Pandemic.

There is no “benefit of the doubt” given to Health Plans. Just ask the large, national insurers that are up to their elbows in lawsuits for allegedly submitting billions of dollars in false Medicare Advantage claims. And that’s just for services and claims that are traditional encounters.

Telehealth is a whole new world, and I’m concerned that Providers and Health Plans are not performing audits on their network providers and vendors. Are these government audits waiting to happen?

Prepare with Proactive Self-Assessment

Since there hasn’t been much guidance on how to ensure compliance and measure quality for virtual encounters from the CMS, DOJ, or OIG, these are 4 self-assessment questions we recommend asking yourself and your team:

    1. What are you doing to keep tabs on your vendor partners and providers?
    2. How are you reviewing the encounters to measure the quality of the visit and guarantee a positive Member/Patient experience?
    3. Are you performing a 100% audit on your Telehealth encounters to avoid RADV exposure and maintain compliance for Risk Adjustment payments?
    4. Is your clinical care management team synced up with your network providers and vendors to ensure continuity of care, closing the feedback loops similar to recommendations for a traditional In-Home Assessment?

I’d encourage you to take a second look at your existing compliance program and reevaluate it to include Telehealth – not just for clinical documentation and Risk Adjustment, but for Member Experience. Times are tough, so don’t make them harder by exposing your health plan or medical practice to avoidable government audits.

Do the work upfront and mitigate the risk.

Daniel Weinrieb
EVP, Government Programs