By Waseem Ghannam, MD, MBA, MHSA
COVID-19 turned the world both upside down and inside out, and it has brought out the best and worst in human nature. Every industry, from supply chains to healthcare, has scrambled to deal with the onset of the highly contagious novel coronavirus while trying to figure out how to keep services—especially essential services—going strong. Healthcare was one of the first sectors to be tested by the virus. From the Centers for Disease Control and Prevention in Atlanta to the World Health Organization in Geneva, doctors, infection control experts, and almost all healthcare professionals were activated to help understand the threat, slow the spread, and design ways to continue seeing patients.
The contactless healthcare track that was easiest to implement on a moment’s notice was telehealth. This was mainly because it had already been around for several years (though in an infancy stage), and because America had already seen smartphone technologies proliferate into the mainstream.
When the COVID-19 pandemic began in the U.S., one of the first action items to help the healthcare sector continue to treat patients was the temporary lifting of a variety of federal restrictions against telehealth usage. These changes, announced by Medicare chief Seema Verma, unleashed telehealth from HIPAA regulations that had historically hampered the adoption of telemedicine across state lines. The changes allowed the use of communication technology that was not HIPAA compliant and approved dozens of new billing codes to enable medical professionals to itemize and bill Medicare for telehealth services.
This move was both good and bad. On the one hand, the lifting of regulations improved access, opening the doors to widespread adoption of telemedicine (and corresponding provider reimbursement) across almost all specialties. On the other hand, some providers surfaced to take advantage of the relaxed regulations and launched industrywide billing fraud and abuse of the technology, increasing the risk to patient safety.
Telemedicine is an essential track in healthcare today. The benefits are clear, not only for patients but for healthcare providers as well. Beyond providing quality healthcare access from the home or office, physicians can create an additional revenue stream and meet with a significant number of patients daily. From my experience, once patients witness the benefits of a telemedicine appointment, they find it unnecessary to return to traditional in-office visits. Recent data supports this trend. In a report published on July 28, HHS reported on Medicare beneficiaries’ usage of telehealth during the pandemic thus far. That data demonstrated that nearly half (43.5%) of Medicare primary care visits were provided through telehealth in April, compared with less than 1% (0.1%) in February before COVID-19. In an unrelated survey conducted by IQVIA, data showed that providers do not expect telehealth visits to go back to baseline levels once the threat of COVID-19 subsides, either through the introduction of a vaccine or the success of social distancing measures. Providers reported that patient visits conducted via telehealth jumped from 9% to 51% at the onset of the pandemic. It is expected that levels will fall back to 21%, which is still a considerable surge from the pre-COVID-19 numbers. That is double-digit growth in a brief period.
With these positive trends showing the staying power of telemedicine in mainstream healthcare, some unsavory players have taken advantage of the pandemic and launched a litany of fraud schemes, preying on the most vulnerable patients. The main telehealth fraud scheme involves the new Medicare billing codes, where overbilling and upcoding are used to inflate the time and complexity of visits. Additionally, some providers are unbundling and billing for multiple procedures as separate claims to increase fees and reimbursement, instead of using the procedure codes designed explicitly for telehealth treatment. Other areas of fraud include billing for services that were never offered and billing for unnecessary services, tests, and durable medical equipment (DME). One of the more egregious fraud schemes is the practice of billing for phantom patients (patients that never existed) or offering kickbacks in exchange for prescribing unneeded tests or DME.
Telemedicine fraud was an issue before the pandemic and, like many other types of fraud, was commonly leveled at elderly patients who may not be tech savvy. In September 2019, the Department of Justice (DOJ) charged 35 defendants in a scheme to prescribe unnecessary cancer genetic tests that cost over $2.1 billion in losses. And fraud schemes have surged during the pandemic. In April 2020, a Georgia woman was charged with paying illegal kickbacks to providers ordering DME for thousands of patients, in a scheme that cost taxpayers more than $60 million in fraudulent claims.
As the DOJ continues to investigate false claims, there are other issues, though less severe, that need to be addressed sooner rather than later. For example, though the regulations requiring HIPAA-compliant technical infrastructures were relaxed to promote the use of telehealth, these regulations should return very soon; they are needed to create secure connection points and protect patient privacy.
As the physician owner of a telemedicine company, TeleHealth Solution, I took the time to build a proper IT infrastructure that protects both the patient and the physician. Imaging technologies, private connection point portals, access to technical support, and compliant integration of electronic medical records are just a few advantages of my company’s telehealth services.
I started my company to serve patients in skilled nursing facilities. This patient population requires the most reliable telehealth infrastructure and protocols in offering digital medicine. Both patients and healthcare facilities looking for turnkey telehealth solutions should consider the stringent HIPAA compliance laws that will soon be reinstated. Regulations will likely increase to combat fraud, and all programs should comply with the temporary waiver allowed by the federal government.
Telemedicine is an exciting and efficient healthcare track allowing the treatment of more patients in rural and urban settings. In my opinion, it is a vital part of a thoughtful and patient-centric model. I sincerely hope that the interest in and adoption of this technology can survive the pandemic. It offers incredible benefits to both patient and provider when deployed safely and appropriately.
Waseem Ghannam, MD, MBA, MHSA, is co-founder of TeleHealth Solution.