Your Telemedicine Could Be Opening the Door to a Compliance Nightmare

The following is a guest article by Dr. Waseem Ghannam, co-founder of TeleHealth Solution.

When the COVID-19 pandemic began in the U.S. in March, telemedicine quickly became the go-to-approach for most medical visits as it offered a solution that allowed effective care without risk to patients or providers. The advent of the pandemic also resulted in changes to the HIPAA restrictions that had historically hampered the adoption of telemedicine across state lines and without HIPAA-compliant technology. These changes improved access and opened the doors to widespread adoption of telemedicine across almost all specialties, as well as allowed for reimbursement of providers for telemedicine visit. However, as with almost every payment change in healthcare, providers have surfaced who have taken the opportunity posed by deregulation to take advantage and commit fraud.

Telemedicine is clearly here to stay. The benefits are clear, and as I know from personal experience, once they’ve experienced telemedicine, patients won’t want to go back to visits when they aren’t necessary. The data is starting to come in to back this up. In a report published on July 28, 2020, HHS reports on the usage of telehealth by Medicare beneficiaries during the pandemic, and the numbers show that nearly half (43.5%) of Medicare primary care visits were provided through telehealth in April compared with less than one percent (0.1%) in February before the public health emergency (PHE). Another provider survey conducted by IQVIA reports that providers do not expect telehealth visits to go back to baseline levels after the PHE. Providers reported that they were holding just 9 percent of visits via telehealth prior to the PHE, that it surged to 51 percent during the PHE, and that they expect levels to fall back only partially, to 21 percent, after the PHE abates.

It’s quite clear that telemedicine is here to stay, with or without the pandemic, but how big a problem has fraud become? Telehealth fraud schemes include:

  • Overbilling, upcoding by inflating the time and complexity of visits to increase fees,
  • Unbundling, billing multiple procedures as separate claims to increase reimbursement instead of using global or broader procedure codes,
  • Billing for medically unnecessary services, tests and durable medical equipment (DME),
  • Billing for services that are not provided, and
  • Outright fraud like billing for phantom patients who do not exist or offering kickbacks in exchange for a physician prescribing or ordering DME or tests that aren’t needed.

Telemedicine fraudsters tend to prey on the most vulnerable patients, and as long term care facilities have gone from in person rounds to telemedicine visits, fraud has become an increasing issue. Telemedicine fraud was already an issue before the pandemic, in September of 2019 the Department of Justice charged 35 defendants in a scheme to prescribe unnecessary cancer genetic tests that cost over $2.1B in losses. It continues during the pandemic, in April of 2020, a Georgia woman was charged with paying illegal kickbacks to providers ordering DME for thousands of patients, in a scheme that caused over $60M in losses.

Amidst the surge of activity resulting from the pandemic, less serious problems like failing to use HIPAA compliant networks are permitted under the relaxed guidelines, but this is likely to be required again when at least some of the rules are reinstated post-pandemic. As the physician-owner of a telemedicine company, TeleHealth Solution, I started my company to serve patients in skilled nursing facilities with the best that telemedicine can offer. Skilled nursing facilities need to use care in selecting the telemedicine and telehealth providers that participate in their digital medicine strategies going forward.

Nursing homes should look for companies that combine virtual telemedicine services with on premise equipment and capabilities, so basic testing and monitoring can be performed on site by existing staff, keeping patients away from COVID-19 and out of emergency rooms. While many companies offering telemedicine software and services have joined the adoption surge by adding services or entering the market during the pandemic, skilled nursing facilities should be wary of providers who do not have experience in the space. Similarly, HIPAA compliance has been waived in the short term, but buyers should seek technology from reputable providers who are HIPAA compliant or have that capability on the near-term roadmap, so that they don’t have to reimplement solutions when the rules are reinstated, in whole or in part.

My own experience as a hospitalist led me to want to improve the patient experience, protect the integrity and dignity of the most vulnerable patients, and connect and support patients, both at home and in the hospital when it’s necessary. Telemedicine can be a wonderful thing when the technology is applied and used in a thoughtful and patient-centric model. I sincerely hope that the interest in and adoption of this technology survives the pandemic, because of the amazing benefits it can offer patients when deployed safely and appropriately.

About Dr. Waseem Ghannam

Dr. Ghannam obtained his Medical Degree from St. Matthew’s University and completed his training at Cabarrus Family Medicine in Concord, NC. During his medical training, Dr. Ghannam also completed a Masters of Business Administration from Davenport University and a Masters in Health Services Administration from St. Joseph’s College of Maine.  Dr. Ghannam began his career as part of a private hospitalist group. There he developed an interest in bridging the gap for local hospitals with physician staffing needs. He and his business partner Dr. Jason Perlman founded The Hospitalist Solution, which gave North Carolina hospitals a one-call solution for their short- to medium-term hospitalist staffing needs.  Dr. Ghannam is a patient-focused physician with a particular interest in creating ways for physicians and patients to interact and be cared for without geographical constraints. Dr. Ghannam is constantly seeking innovations in technology that can provide unparalleled care. When he is not involved in patient care, Dr. Ghannam is very active with his two children, attending professional sporting events, and enjoying lake activities.