Effectively Utilizing Payment Integrity Solutions to Support Compliant Telehealth Billing

By Subrahmanyam Mantha, Vice President, Payment Integrity, HGS Healthcare

The U.S. The Department of Health and Human Services is expected to end the COVID-19 Public Health Emergency this summer. To lighten the number of regulatory changes that will immediately follow, Congress has granted a five-month extension to telehealth flexibilities created during the pandemic as part of the sweeping Omnibus Spending Bill approved in March 2022. 

These changes provide patient-centric benefits, such as allowing adults aged 65+ to use Medicare coverage for telehealth visits, regardless of location. Under these flexibilities, all Medicare-enrolled providers can bill for telehealth services taking place from the patient’s home as well as from medical facilities. The bill will also postpone the requirement that older adults who seek virtual mental health care have an in-person follow up appointment within six months. 

While the benefits to members are clear, greater telehealth flexibilities can create more confusion among providers around billing guidelines and requirements, along with leaving more room for healthcare billing fraud, waste, and abuse (FWA). With providers seeing 50 to 175 times the number of patients via telehealth than before the pandemic and the introduction of several complex policy waivers and expansions from CMS to accommodate the surge in telehealth services, FWA often occurs through potential coding and payment aberrations from providers, which payers must mitigate.

As payers and providers alike grapple with compounding operational challenges due to new realities caused by the COVID-19 pandemic, their relationship is further strained due to knowledge gaps surrounding everchanging CMS guidelines and documentation requirements for smooth claims processing. These learning gaps often intensify billing and coding errors between payers and providers. Whether intentional cases of FWA occur or billing knowledge gaps exist, both can lead to costly consequences. 

In April, The Department of Health and Human Services, Office of Inspector General, along with their law enforcement partners, participated in a sweeping, coordinated law enforcement action to combat COVID-19-related health care fraud.

Twenty-one defendants in nine federal districts across the United States were charged for their alleged participation in various health care fraud schemes that exploited the COVID-19 pandemic and resulted in over $149 million in false billings. Defendants include telemedicine companies, physicians, marketers, and medical business owners.

Prior to the pandemic, telehealth spending was low, so there was little auditing into these types of claims. When regulations and spending shifted from in-patient, to out-patient, to more home care and telemedicine, it created a lack of interpretation of guidelines to conduct proper coding and billing. Thus, as the prevalence of telehealth grew, so did increasing risks of coding e-visits or virtual check-in claims to higher level telehealth visits, as well as up-coding of evaluation and management (E&M) services to a higher level of service than actually rendered. This increase in higher reimbursement often creates issues of overpayment or waste and abuse. According to Medical Billing Advocates of America research, 80% of medical bills contain errors and, while the expansion of reimbursable telehealth services may drive an increase in such errors, it is incumbent upon payers to identify these cases of FWA – or risk overpayment.  

The practice of identifying instances of FWA to increase payment accuracy and reduce overall spending waste is often referred to as payment integrity. To help fill some of the knowledge gaps around telehealth billing and interpretation of CMS guidelines, payment integrity solution providers serve as a key driver for improved accuracy of information between provider and payer. Along with a more collaborative relationship with payers to help educate providers on effective standardized billing patterns, leveraging payment integrity solutions can help mitigate post-pay audit issues associated with the par/nonpar provider in relation to new regulations around billing processes.

Resource-constrained payers must harness technology, such as analytics, AI, and automation to tackle payment integrity efficiently and cost-effectively. Payment integrity solution providers are expert problem solvers who can utilize their exposure and understanding of the nuances of the COVID-19 telehealth impact to assist payers with this task. Taking aim at critical impacts like recoupments according to payment risk while also uncovering significant savings opportunities and reducing provider strain and coding errors. Precise, end-to-end payment integrity has never been more essential to health plan operational costs as well as the quality of the service delivered to members and providers.

Subrahmanyam Mantha (Mantha) runs the Payment Integrity practice for HGS Healthcare. He is an accomplished senior management executive with strong operations and leadership skills to build business verticals and organizations in the BPO/KPO/Analytics space in insurance, healthcare, and financial services.