Managing fraud, waste and abuse during the expansion of telehealth

Recently there have been great strides made in healthcare through the increased use of telehealth technology.

The concept of being examined by a physician through the push of a button on your phone, computer or other device is no longer a concept. It is now something that is happening across the country and may be the most rapidly growing subsector in the healthcare industry.

Telehealth is creating new pathways to healthcare services in places where access is limited (such as rural areas) or in situations where individuals are unable to physically travel to a provider. Additionally, as the U.S. faces a shortage of physicians and other providers, telehealth is helping address this critical gap and may also generate new cost savings for payers.

As virtual care and telehealth transform how healthcare is delivered, policymakers and regulators have been called upon to update the regulatory framework to ensure this type of care is delivered appropriately and safely. For example, Bruce Greenstein, chief technology officer for the Department of Health and Human Services, recently called existing telemedicine regulations “arcane.” He also noted there is “a lot of friction” between government regulations and virtual care innovations.

As new regulations are created to ensure quality of care and appropriate reimbursement of telehealth providers, one area that cannot be ignored is preventing and detecting fraud, waste and abuse in a virtual care setting.

Because telehealth expands access to different providers, it also expands exposure to fraud and abuse. Much like the home care industry, which has become a hot target for fraudsters who frequently bill for fictitious visits and services, telehealth interactions are likely to face the same problems.

As an executive of a healthcare cost-containment and analytics firm, I recognize and support the immediate benefits telehealth brings to the healthcare system. That said, I am also well aware of how fraudsters target healthcare programs such as Medicare through complex billing schemes. If vulnerabilities are not properly addressed in the virtual care setting, it also will be susceptible to fraud. Additionally, as with all new oversight measures, provider outreach and education are just as important to ensure providers are aware of compliance requirements.

For example, in 2016, the first telehealth false claims case was settled with a provider. In this case, a Connecticut psychiatrist was repeatedly billing Medicare for services he provided over the phone to patients who were not in approved rural health professional shortage areas. Though this case may not have been part of a grand scheme to defraud Medicare, it does serve as evidence of how the virtual nature of telehealth makes it vulnerable to both true fraudsters as well as providers who may just be unaware of telehealth reimbursement requirements.

The bottom line is that our healthcare system is in an exciting and dynamic time where new innovations and technology are quickly transforming the delivery of care. We need polices and regulations to be in lockstep with these advancements. That includes incorporating safeguards to protect and prevent fraud, waste and abuse in telehealth.

If we can push a button to receive instant care, then we certainly have the capability to ensure the care is actually received and properly billed.

Michele Carpenter is Senior Vice President of HMS Holdings (NASDAQ: HMSY), a healthcare technology company that provides services to more than 45 Medicaid agencies and over 200 Medicaid health plans.

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