Understanding Telehealth & Telemedicine Fraud: The New Frontline in Medicare False Claims

A new and effective way for doctors and patients to communicate is through telehealth and telemedicine. Sometimes both are referred to as eHealth.

Doctors now have the ability to provide care without physically seeing the patient. This service is available for patients living in rural areas farther away from a certified medical care facility.

Telemedicine and some telehealth provided medical services can be covered by Medicare, Tricare and Medicaid.

Medical clinics, Doctors and Pharmaceutical companies should be aware of this popular new and innovative option for patients.

The Office of the Inspector General (OIG) reported in November 2017 that “Medicaid programs are seeing a significant increase in claims for these services and expect the trend to continue.” ^[1]

The increase prompted the OIG to update the rules and regulations governing reimbursement of Medicare, Tricare and Medicaid eHealth claims.

The modernized regulations help guide Doctors and Medical care facilities with the proper use of covered services. Knowingly taking advantage of these services using false claims is considered fraud.

As Federal and State governments refine reimbursement for online medical care policies some unscrupulous medical and pharmaceutical providers are taking advantage of the system.

Telecare Violations: Turn Them In

Medical professionals know that making false Medicare or Medicaid claims for in-person is considered fraud. The same applied for telemedicine and telehealth.

Medicare Fraud is covered under the False Claim Act.

Federal and State Governments use the False Claims Act to empower those who have knowledge of wrongdoing and report them.

You can also report Medicare Fraud anonymously.

Telemedicine uses the same Medicare claim guidelines that apply to in-person care with additional rules for covered services.

Before reporting or bringing a case for telemedicine fraud it is important to understand the difference between telemedicine and telehealth.

Telehealth and telemedicine are considered two different types of online healthcare.

Both utilize electronic means to deliver medical services, treatments or prescriptions. This allows them to be defined as eHealth or telecare service.

The electronic means for clinical services include:

• Doctor/Patient Videoconferencing
• Internet Communication
• Store-and-forward Technologies
• Streaming Media
• Wireless Communications
• Telemonitoring Service
• Email, Fax, Text Communication
• Prescription of Drugs

According to the Office of the National Coordinator for Health information Technology (ONC) - “telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.” ^[2]

This general description is helpful, but specifically defining the difference between telemedicine and telehealth services is important for understanding what is covered by Medicare Part B, Medicaid or Tricare.

Telemedicine and Telehealth are new technologies. Newer advancements in medical treatments make life easier for patients but create a potential for abuse.

However, these innovations in healthcare are more difficult to regulate. As Medicare and other healthcare programs cover these innovative services new fraud schemes follow along.

The Department of Justice, the US Attorney General's Office and State Attorneys need help identifying complex and new illegal schemes.

Medical professionals should consult with a qualified Qui Tam Attorney to help bring cases if they believe a pattern of fraudulent action is in fact occurring.

In October 2018 four people and seven companies were indicted in a $1 Billion dollar telemedicine fraud scheme. The scheme involved the defendants setting-up a complex telemedicine process.

HealthRight, LLC, using other complicit pharmacies, fraudulently requested insurance coverage and prescriptions from people all over the country according to the indictment.

Doctors and clinics were approving drugs without even knowing the defendants where massively marking-up the prices and billing private insurance carriers.

While the private insurance carriers are not covered directly by the FCA, in many cases there is overlap with Medicare and Medicaid. This would allow for broader application of the False Claims Act.

This example is just the beginning of the new fight that awaits Medicare, Medicaid and Tricare in the future.

These government programs are typically slower to react and enforce change.

The government will rely on the public and medical professional to help.