Cracking Down on Medicare Telehealth Fraud: The Push for Accountability Amidst Extension Talks
Congress is taking decisive steps to shape the future of telehealth in light of ongoing and new concerns regarding fraud, waste, and abuse.
The House Ways and Means Committee recently advanced a two-year Medicare telehealth extension bill, furthering efforts to extend benefits set to expire at the end of 2024. Congress is also weighing several other pieces of legislation that could make pandemic-era Medicare telehealth flexibilities permanent.
While lawmakers have expressed bipartisan support for these bills, many are concerned about fraud, waste, and abuse (FWA) of telehealth benefits, particularly for unneeded durable medical equipment (DME) and diagnostic tests.
With so much at stake, payers must closely monitor telemedicine initiatives. This article explores how healthcare payers can safeguard their organizations' payment integrity operations from fraudulent telehealth claims.
Key Takeaways
- Congressional action on telehealth: Congress is shaping the future of telehealth with a two-year Medicare telehealth extension bill.
- Concerns about FWA: Bipartisan lawmakers are concerned about fraudulent claims, especially for unneeded DME and diagnostic tests.
- The magnitude of fraud schemes: Law enforcement agencies are investigating and prosecuting telemedicine fraud cases that total billions of dollars.
- Importance of monitoring and prevention: Healthcare payers should monitor DME, diagnostic tests, and other claims to prevent the approval of fraudulent claims.
- Technology-driven payment integrity: Advanced technological solutions, such as robust artificial intelligence (AI) tools, can safeguard payer finances and ensure payment integrity by detecting fraudulent claims.
Multibillion-Dollar Schemes Target Medicare's Telemedicine Benefits
Lawmakers are rightly concerned about fraudulent claims as the Federal Bureau of Investigation (FBI) and Department of Justice (DOJ) are investigating and prosecuting high-profile cases of telemedicine FWA.
In 2023, the DOJ and federal and state law enforcement partners' nationwide law enforcement action resulted in charges against 78 defendants for alleged healthcare fraud and opioid abuse schemes totaling over $2.5 billion.
Among these charges, 11 defendants were accused of telemedicine fraud, including a case in Florida involving a massive scheme to sell templated doctors' orders for orthotic braces and pain creams, resulting in $1.9 billion in fraudulent claims to Medicare.
In addition, telemarketing operations targeted elderly and disabled individuals to sell unnecessary medical equipment and prescriptions.
Another case in Washington involved a physician signing over 2,800 fraudulent orders for orthotic braces, even for patients who had amputated limbs. These cases add to previous telemedicine enforcement actions totaling over $10.1 billion in fraud.
By comparison, in 2022, telemedicine fraud schemes represented over $1 billion of the total alleged intended losses from similar enforcement actions by federal agencies.
Shocking Cases That Cost Medicare Millions
Check out these two telemedicine FWA cases involving diagnostic tests and DME. Multiple law enforcement agencies investigated and prosecuted each case.
Case 1: Nurse Practitioner's $7.8 Million Telemedicine Fraud Lands Her Behind Bars
A nurse practitioner from Virginia was sentenced to 18 months in prison for her participation in a $7.8 million telemedicine fraud scheme involving unnecessary DME.
She signed over 2,000 DME orders without assessing patients, often without even reading the orders. These orders were then sold to DME suppliers, resulting in fraudulent Medicare claims.
Case 2: Inside the $192 Million Medicare Scam That Landed a Florida Woman in Prison
In another prominent case, a woman from Florida was sentenced to 20 years in prison for her role in a Medicare fraud scheme totaling over $192 million.
She submitted claims for unnecessary genetic tests, orthotic braces, and telemedicine visits that never happened—signing off on thousands of orders for these services without ever examining or treating patients. She often had others, including non-licensed individuals, sign her name for fraudulent orders.
The Florida woman personally profited around $1.6 million from the scheme, using the money for lavish purchases.
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There's More to Uncover
In addition to the cases mentioned, numerous instances of telehealth fraud demonstrate the importance of healthcare payers closely monitoring DME, diagnostic tests, and other claims through meticulous reviews.
Prevent Fraudulent Telehealth Claim Approvals with AI-Powered Solutions
So, how can healthcare payers avoid paying for fraudulent telehealth claims, especially as extending telemedicine coverage beyond 2024 becomes more likely and efforts to make telehealth benefits a permanent part of the healthcare landscape seem increasingly real?
Payers don't want to risk approving fraudulent claims for expensive DME and diagnostic tests. And with Alaffia Health, you don't have to.
Keep your claims processing operations running smoothly, efficiently, and cost-effectively with tools such as Ask Autodor. This Next-Gen AI platform supercharges your claims operation and makes it faster than ever imagined.
Did you know that up to 80 percent of medical claims have errors? Alaffia Health is here to help detect and prevent unnecessary overpayments before they occur.
Our platform seamlessly integrates into your existing systems with no disruptions and provides immediate results. AI technology enables us to audit more claims, leading to groundbreaking recoveries.
The best part is that several case studies prove the tremendous value of Alaffia Health's AI-powered solutions. Check them out for yourself here!
Ensure Payment Integrity Amidst Growing Demands
In addition to combatting FWA in the healthcare system, payers must also deal with the crushing realities of running a claims processing and payment operation in today's healthcare business environment.
As margins shrink and demands on our healthcare system increase, Alaffia Health understands that healthcare payers feel tremendous pressure to do more with less. So, to meet your members' needs, your healthcare payer organization must become more efficient than ever.
Due to the high volume of documentation, billing, and paperwork for each claim, it's unsurprising that overpayments occur and most FWA costs slip through the system.
Generate Claims Savings with Alaffia Health's Advanced Technological Solutions
This article focused on the current efforts to expand Medicare telehealth benefits and potentially make them permanent. It also addressed the critical need for accountability and preventing FWA in telehealth services.
The good news is that you don't have to face these challenges alone as a healthcare payer, as Alaffia Health's powerful solutions are readily available!
Our sole reason for existing is to partner with payers to prevent overpayments and ensure payment integrity.
Do you have a claim that has already been paid out? Don't worry; we also have the capability and technology to conduct post-payment reviews.
Schedule a call with Alaffia Health today, and we will demonstrate how our technology and team can protect your organization from overpayments and deliver immediate and significant results.
If you suspect healthcare fraud, please click here for a list of agencies where you may file a complaint.