Fraud Schemes in a Telehealth Era: What Healthcare Payers Should Know

What You Should Know:

– Report from Codoxo that finds 10-15% of telehealth claims fall outside of approved CMS codes and indicates a high potential for rapidly increasing fraud schemes (and provider coding errors) in a new telehealth era.

Codoxo, a provider of healthcare artificial intelligence solutions for healthcare payers and agencies, today released a new study revealing that among the 41% of provider specialties showing statistically significant increases for telehealth adoption, up to 15 percent of telehealth claims are non-compliant with CMS guidelines.

Report Background

The report, “Fraud Schemes in a Telehealth Era: What Healthcare Payers Should Know,” highlights provider specialties where telehealth modifiers were used but lack accompanying eligible CMS billing codes, which may indicate wasteful, abusive or erroneous practices and warrant immediate investigation. Codoxo’s study was conducted over claims submitted across various geographic regions from September 2019 to July 2021.

Within the first three weeks of the WHO declaring the COVID-19 pandemic, telehealth visits skyrocketed 154 percent, according to the Centers for Disease Control and Prevention, compared to the same time period just one year prior. After sharply peaking in April 2020, telehealth has since leveled off, finding a new elevated steady state at approximately 20-times higher than pre-COVID rates, according to Codoxo’s anonymized health plan data.

Telehealth Spend

Starting in May 2021, the percentage of spending on telehealth appears to stabilize at 4.5%, a level approximately 20 times higher compared to the pre-COVID era. The new baseline appears non-reactive to the emergence of new COVID-19 cases.

Top 20 Provider Specialties Adopting Telehealth

1. Physician/Psychiatry

2. Licensed Clinical Social Worker

3. Hospital-Psychiatric Unit

4. Psychologist, Clinical

5. Physician/Physical Medicine & Rehabilitation

6. Physician/Neuropsychiatry

7. Physician/Addiction Medicine

8. Physician/Endocrinology

9. Certified Clinical Nurse Specialist

10. Physician/Family Practice

11. Physician/Geriatric Psychiatry

12. Physician/Geriatric Medicine

13. Physician/Emergency Medicine

14. Physician/Hospice and Palliative Care

15. Physician Assistant

16. Nurse Practitioner

17. Physician/Internal Medicine

18. Physician/Sleep Medicine

19. Registered Dietitian or Nutrition Professional

20. Physician/Medical Toxicology

“Any time we see significant changes in the healthcare industry and radical shifts in billing patterns, bad actors find a way to take advantage of those transitions. The boom in telehealth was no exception,” stated Musheer Ahmed, Codoxo’s Founder and Chief Executive Officer. “But if healthcare payers and government agencies can quickly identify, investigate, stop, and prevent suspicious telehealth activity and incorrect payments, the entire healthcare ecosystem benefits by avoiding massive, unnecessary, and otherwise avoidable costs.”

For more information, download the full report here.

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