Coronavirus fuels explosive growth in telehealth ― and concern about fraud

Reviewed by James Ives, M.Psych. (Editor)Apr 22 2020

On March 17, Medicare chief Seema Verma stepped to the podium at a White House coronavirus briefing and unveiled a "historic action" to promote virtual medical care, or telehealth.

Verma temporarily lifted a variety of federal restrictions on the use of the service, which had been limited to rural areas. She praised telehealth, saying it could handle routine care for an older patient with diabetes without risking a visit to a medical office. She said a Medicare recipient with mild flu-like symptoms could receive advice from a doctor at home "instead of leaving the house and sitting in a waiting room full of other vulnerable people."

But the Trump administration's action also raised concerns that it could inadvertently unleash a wave of billing fraud and abuse and risk patient safety — especially if officials yield to industry pressure to make many of the emergency policy changes permanent.

"There are unscrupulous providers out there, and they have much greater reach with telehealth," said Mike Cohen, an operations officer with the Health and Human Services Inspector General's Office, which investigates health care fraud. "Just a few can do a whole lot of damage."

Telehealth — or telemedicine, as it's also known — covers a broad range of services via video, telephone or email. In early March, the Centers for Medicare & Medicaid Services approved dozens of new billing codes to allow medical professionals to bill for these services. That means patients can consult with doctors about everything from flu symptoms or a backache to a psychiatry visit.

Federal officials also allowed telemedicine providers to waive patient deductibles and copayments during the coronavirus emergency. Under normal conditions, these actions can be construed as a kickback because they discourage patients from complaining about charges or can lead to overuse of medical services. Such tactics normally can lead to civil or criminal penalties.

Cohen said anti-fraud "guardrails have been removed under this epidemic. The concern is that things will never go back to what they were. … There will be a lot of pressure on CMS to make at least some of these changes permanent."

Officials worry that some telemedicine companies may take advantage of Medicare patients they contact at their homes. Some of the largest recent Medicare fraud cases have implicated this sort of marketing, often for bogus genetic testing, or prescribing unnecessary pain creams or delivering unwanted medical equipment. In some cases, the companies have employed telemarketers to call thousands of people on Medicare and offer them a free service in order to obtain their patient ID numbers, which can be used to bill the government.

These fraudulent activities can become massive because phone rooms operating anywhere in the world can target thousands of patients and Medicare may have difficulty differentiating improper bills from those submitted by a legitimate telehealth operation.

In September 2019, the Justice Department charged 35 people in connection with a telemedicine scheme that allegedly ripped off more than $2.1 billion from Medicare, among the largest such frauds in U.S. history.

Cohen said investigators already are seeing "tons" of fraud cases linked directly to COVID-19, including using patient accounts to bill for "coronavirus emergency kits" that contain nothing but gloves and hand sanitizer or bogus testing kits. Once marketers obtain a patient's billing numbers, they often tack on thousands of dollars in genetic tests that are of no value to the medical case, investigators said.

Other rollbacks in telehealth regulations could prove controversial and affect patient safety — from relaxing restrictions on opioid prescriptions via video to easing licensing requirements for doctors who practice across state lines.

In a statement to Kaiser Health News, CMS said it is "instructing its payment and audit contractors to review claims during this public health emergency based on all agency waivers and flexibilities that have been put into place. This includes claims for services furnished under the telehealth flexibilities." CMS also said it would put "a strong emphasis" on program integrity and cost in considering whether to make any telehealth changes permanent.

The telemedicine industry argues that its operations are no more prone to billing abuses than any other branch of health care.

"A crisis always spawns fraudsters," said Krista Drobac, executive director of the Alliance for Connected Care, which advocates for telehealth.

She said the alliance hopes "to show the value of telehealth" and help win wide acceptance of virtual visits to doctors. The group wants to see some of the regulatory changes made permanent in order to assure the industry's viability once things return to normal.

Telehealth advocates also argue they have successfully stepped in to fill a void caused by many doctors temporarily shutting down their offices.

The coronavirus has "stopped [the medical] profession in its tracks, and we need to adapt to a new reality," said Dr. Joseph Kvedar, a Harvard Medical School professor and president-elect of the American Telemedicine Association, a nonprofit that promotes access to the technology.

Kvedar said virtual visits at Partners HealthCare, where he is a senior adviser, have jumped from 1,600 virtual visits in February 2019 to 90,000 in March.

He said other health networks have reported similar spikes, in one case in New York City ramping up from zero to 5,500 visits in a single day. "There's a lot more interest now that people have to stay home."

Congress did much to speed acceptance of telehealth as part of the $2 trillion stimulus package. The CARES Act awards $200 million through the Federal Communications Commission to medical groups to help them install the technology and fund broadband installations. The groups also can apply for $27 billion in a public health emergency fund.

In the March 17 briefing, Verma added that CMS wanted to give medical professionals relief from regulations that could take time away from treating patients.

"In an emergency, those on the front lines shouldn't have to worry about federal rules and red tape hamstringing them when they need flexibility above all else. And we're doing everything in our power to make sure that that doesn't happen," Verma said.

CMS also is allowing Medicare Advantage plans, which together treat more than 22 million Americans, to use telehealth to help set payment rates. On March 30, CMS said it would suspend some efforts to recover hundreds of millions of dollars in overpayments made to the health plans.

Lindsey Copeland, federal policy director for the Medicare Rights Center, said her group agreed that telehealth could help ensure that people on Medicare would "not be forced to put themselves in harm's way to obtain needed care."

Copeland said making some of the telehealth changes permanent might make sense. But she said, "We urge caution in rushing such policymaking."

By contrast, the industry sees itself as on a roll. InSight + Regroup, a national telepsychiatry company, noted that it "feels strongly about advocating to keep the telehealth-friendly regulations that were rapidly put into place in response to COVID-19."

"Telehealth is going mainstream," said company CEO Geoffrey Boyce. "It has been on the fringes for a number of years. We're at the point now where there is no going back."

His company also wants to reverse Medicare's prohibition on doctors living outside the U.S. treating patients here using telehealth. Boyce said the company would use only doctors who trained and are certified in this country.

There's little doubt that the coronavirus crisis has brought telehealth to the forefront of medicine, something that years of lobbying in Washington couldn't accomplish.

The Alliance for Connected Care, a group that advocates telehealth and whose more than three dozen members range from Amazon to the Michael J. Fox Foundation for Parkinson's Research, spent more than $1 million on lobbying from 2016 to 2019, according to the Center for Responsive Politics.

But now "the numbers of [virtual] visits are astounding," said Drobac, the alliance's executive director.