Seven telehealth billing practices are red flags to the OIG

Is your behavioral healthcare organization analyzing its own Medicare telehealth claims data to assess potential program integrity risks?

Many of SimiTree’s behavioral healthcare clients overlook this essential step in operating an effective telehealth program – and in doing so may unnecessarily open themselves to risk, including investigations for fraud and abuse. 

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services strongly encourages providers to self-audit. It even provides a Red Flag List of exactly what to look for: the seven most likely reasons telehealth claims might trigger investigation for fraud or abuse. 

But many behavioral healthcare providers aren’t using the list of red flags and other helpful compliance information provided in a Telehealth Tool Kit provided by the OIG. Some of them aren’t aware there is one, and others have downloaded it but aren’t sure how to go about setting up the most effective self-auditing processes.

 SimiTree’s certified healthcare compliance experts work with behavioral healthcare providers of all sizes and types to set in place effective tracking measures that easily identify where risks are occurring.

We also help organizations develop mitigation plans unique to the organization to shore up compliance and insulate against audits and/or claims denials --  and deter fraud investigations from occurring.

CMS, behavioral health and telehealth

Medicare has embraced behavioral healthcare since the COVID-19 pandemic, recognizing the direct correlation between mental health conditions or substance use disorders and poor physical health.

Some of the recent developments highlighting Medicare’s heightened interest in behavioral healthcare include:

  • A new payment model announced at the start of 2024 by the Centers for Medicare and Medicaid Services (CMS). The goal of the new Innovation in Behavioral Health (IBH) Model is to support integrated care that meets behavioral health and physical health care needs, and health-related social needs. The IBH Model will launch in the fall of 2024 and run for up to eight years in eight states. Participants will be community-based behavioral health centers, public or private behavioral healthcare practices, opioid treatment programs, and safety net providers where individuals can receive outpatient mental health and substance use disorder services.

  • Expanded billing provisions set out under the CY 2024 Physicians Fee Schedule Final Rule to enable additional types of behavioral healthcare providers to bill Medicare for services.

  • New policies established under the CY 2023 Physicians Fee Schedule Final Rule to allow licensed marriage and family therapists, licensed professional counselors, certified addiction counselors, certified peer recovery specialists, and others who are authorized under state law to provide behavioral health services, to do so under the general supervision of a physician or non-physician practitioner rather than under “direct” supervision. State licensure and scope of practice considerations apply.

  • New telehealth provisions. CMS is also recognizing the important role telehealth plays in the delivery of these expanding behavioral healthcare services. The CY 2024 Physicians Fee Schedule included a host of new telehealth provisions for 2024, as well as new telehealth billing codes.

    Download our Checklist of New Telehealth Provisions for 2024 here

New opportunities, new risks

Medicare’s growing recognition of the importance of behavioral healthcare is creating many new business opportunities for providers as it expands access to behavioral healthcare for Medicare beneficiaries -- but new opportunities bring new risks as well.

As long-time experts in Medicare methodology, SimiTree’s compliance experts caution clients that effective self-auditing is essential for identifying trends, patterns and areas of risk.

Our certified healthcare compliance experts recommend a full compliance assessment for the organization to identify all potential vulnerabilities, followed by the establishment of a risk mitigation plan that establishes regular self-auditing processes.  

We’ll help you track and identify the following seven risky billing practices singled out in the OIG Toolkit – and put into place the detailed compliance guidance for all healthcare providers issued by the OIG in late 2023.

7 telehealth billing practices to avoid

  1. The OIG’s Took Kit targets these seven billing practices that may be linked to fraud, waste, or abuse in telehealth services: 

    Billing both a telehealth service and a facility fee.
  2. Billing telehealth services at the highest, most expensive level, every time.

  3. Billing telehealth services for a high number of days in a year.

  4. Billing both Medicare fee-for-service and a Medicare Advantage plan for the same service for a high proportion of services.

  5. Billing a high average number of hours of telehealth services per visit

  6. Billing telehealth services for a high number of beneficiaries.

  7. Billing for a telehealth service and ordering medical equipment for a high number of beneficiaries.

Access the full OIG Toolkit here

How SimiTree can help

SimiTree works with providers across healthcare settings to ensure billing compliance, reducing healthcare program integrity risks. We show clients how to get a handle on duplicate claims and high-volume billing errors, improve clinical documentation, enact polices and procedures for full compliance, and shore up vulnerabilities.   

Our compliance team is made up of former auditors and Medicare methodology experts who fully understand the medical review process, have experience in implementation of billing controls, and stay abreast of all regulatory changes.

Here are a few other ways our experienced healthcare team can help your organization with its telehealth compliance:   

  • Our HIPAA Privacy Assessment can help providers serving patients through everyday communications technologies ensure that all standards of the HIPAA Privacy and Security Rules are met.

  • New to Medicare billing? Our knowledgeable consultants can help with Medicare enrollment for behavioral healthcare practitioners, and set in place effective billing controls to avoid improper practices. Our billing compliance experts can insulate your organization against audit scrutiny.

  • Maintain compliance with accurate documentation and billing practices. Our certified healthcare compliance experts can review clinical documentation to identify areas of risk and provide the training needed to help your organization mitigate risk.

Reach out to us today and let’s work together to shore up your organization’s telehealth compliance.

NEXT WEEK: A look at the SUD Final Rule  

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Have a compliance question?
SimiTree’s certified healthcare experts can help! Our team is made up of former auditors and surveyors from across healthcare settings. We have the know-how and the experience to help your organization mitigate risk. Contact us today with all your compliance needs.

J’non Griffin serves as Senior Vice President for the Compliance as well as Coding divisions at SimiTree. With a healthcare career that spans three decades, she has a track record of helping many provider types implement effective compliance programs. She has worked with organizations nationwide  to develop compliant emergency preparedness and operation plans, implement fully compliant plans of care, and meet regulatory demands. As an AHIMA ambassador, Griffin was instrumental in preparing the coding community for the launch of ICD-10.