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FWA Insights: Flagging high-frequency telehealth claims

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During the COVID-19 pandemic, telehealth became one of the most convenient ways for members to receive the care they needed, especially for behavioral health services. Yet it has also provided opportunities for bad actors to seek improper reimbursement. Certain flexibilities were allowed to telehealth claims during the pandemic in the name of expanding care, and many of those changes are set to remain for the foreseeable future or have become permanent changes to policy.

As part of our ongoing FWA Insights series, we break down a specific case from our special investigations unit (SIU) involving suspicious billing for behavioral telehealth services.

Discovering the red flag

A particular nurse practitioner was flagged for submitting claims for telehealth services at a higher frequency than peers. Furthermore, the provider billed exclusively for telehealth services with one of the highest-level evaluation and management (E&M) procedure codes (CPT 99214; or established patient office visit, 30–39 minutes) along with an add-on psychotherapy code (CPT 90836; 45 minutes with patient for treating the psychiatric disorders). To be performed via telehealth, certain requirements of these services must be met in order to achieve the appropriate level of complexity without performing a physical exam.

Digging deeper into the data

After this case was passed to our SIU, we reviewed the claims data for the provider’s two-year billing history. The billing history identified the provider as billing telehealth services at one of the highest, most expensive levels every time. The provider billed one of the highest levels of E&M services (CPT 99214) for roughly 200 office visits during the review period, while also billing for psychotherapy services with each of these E&Ms. According to the provider’s claims data, they billed for telehealth services for more than 100 days of the year, compared to their peer average of just 26 days, which was a leading indicator for our team that further analysis into the provider’s utilizations patterns was necessary.

Billing for telehealth for a high number of days combined with the high-level coding patterns can indicate that the provider is not delivering the services at the level indicated or that the provider isn’t delivering the services for which they are billing at all. As a result of the data analysis, records were requested for all claims billed as telehealth which consisted of high-level E&M visits billed in conjunction with psychotherapy services.

Reviewing the documentation

The provider produced medical records for all claims requested. The documentation revealed both E&Ms and psychotherapy services were not supported, and all reviewed claims were ultimately denied due to the documentation not meeting the specifications of the Centers for Medicare & Medicaid Services (CMS) and the health plan’s own policies. Identified deficiencies included:

  • The treatment plan did not contain all the required components.
  • The location of service was unable to be determined. The progress notes did not state the visit was performed via telehealth.
  • The documentation did not include the time spent on services.
  • No documentation of amount, frequency, and duration of the services was furnished.

The results of the medical reviews and the data analysis supported the case being referred to the plan’s SIU for further investigation activities. The plan ultimately requested recovery of all identified overpayments from the provider for these claims.

Key takeaways

Now that the COVID-19 Public Health Emergency has ended, we anticipate seeing a shift to less services being performed as telehealth. However, data trends are not returning to pre-pandemic rates of telehealth billing. For this reason, SIUs and plans should strengthen their monitoring and targeted oversight of telehealth services and stay vigilant against suspicious activity. For example, identify providers who are continually billing telehealth services at the highest, most expensive level, or providers who are billing telehealth services for a high number of visits per patient. Spotting potential issues provides an opportunity to evaluate whether billing is appropriate and to implement measures to prevent future problems.

Proactive communication and focused member engagement can also be extremely helpful, especially in a continuing trend like telehealth services. Delivering additional education to providers on appropriate billing for telehealth services can help them understand the requirements for each type of interaction, which CPT codes apply, and how to bill for them.

Plans should also pay attention to any new modifiers as they can be targets for FWA. For example, there is a new telehealth modifier that went into effect last year, modifier 93, which allows reporting of medical services provided via telephone or other real-time interactive audio-only telecommunications systems. When using modifier 93, patient-provider interaction during the audio-only service must be of an amount or nature that meets the same key components and requirements of face-to-face interaction.

Whether you’re looking for targeted support or an entire outsourced team, Cotiviti’s SIU Services can help your plan to catch FWA in its tracks. Whether you’re looking to outsource your SIU needs, or simply looking to add more support to an existing team, Cotiviti can help. Our SIU Services can help your plan to flag suspicious activity, reduce associated costs, achieve regulatory compliance, and more. Learn more by reading the fact sheet.

About the Author

As vice president of fraud, waste, and abuse (FWA), Erin is responsible for the oversight and strategic direction of Cotiviti’s FWA solution suite. In her role, Erin has been integral in the development of Cotiviti’s FWA solutions over the past eight years. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC).

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