Rapid Rise in Telehealth Leads to Significant Oversight: How to Prepare Now for New Audit Activities


The Pandemic led to a rise in the use of telehealth and a recognition of its value.  When the COVID-19 pandemic began, the use of telehealth to provide healthcare services and enhance access to health care grew at an exponential rate.  The Centers for Disease Control and Prevention (CDC) recognized an increase in the use of telehealth visits by 154% during the last full week in March, 2020.  

The CDC predicted that telehealth could have multiple benefits during the pandemic, including expanded access to care, reduced disease exposure for patients and staff, preservation of personal protective equipment, and reduced patient demand on healthcare facilities.  Almost one year later, in February of 2021, the Deputy Director for the Health and Human Services Office of Inspector General (OIG) recognized the importance of telehealth during the pandemic, calling it not just a matter of convenience, but also “a matter of safety for many beneficiaries.”  

As telehealth is more widely used and expanded, the focus turns to audits and oversight.  The OIG also recognized that there is a robust conversation happening nationally concerning the need for the continuance and expansion of telehealth services when the pandemic ends.  However, the OIG Deputy Director also announced its intentions to conduct “significant oversight” of the new telehealth policies and technologies in order to ensure the benefits of telehealth are not compromised by fraud, abuse, or misuse.  

The OIG, in fact, is in the process of conducting seven audits involving telehealth services.  The OIG’s work plan can be found here. While the OIG’s work plan generally focuses in industry trends, the audits may include the identification of overpayments for specific providers.  Overall, the OIG work plan also points out areas that will be of interest to the various federal, state, and commercial payors as audit targets in the near future. 

The OIG’s audits cover several specific areas plus key technical aspects related to the delivery of telehealth.  Specifically, the OIG’s “Audits of Medicare Part B Telehealth Services During the COVID-19 Public Health Emergency” reflects the OIG’s focus in several areas.  The first phase of the OIG Part B audits will review whether the billing of evaluation and management, opioid use order, end-stage renal disease, and psychotherapy by telehealth met Medicare requirements. 

In phase two of the OIG’s Medicare Part B audits, the OIG will examine distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology, and annual wellness visits.  In other words, the use of telehealth to deliver certain services and the technical requirements for delivering telehealth will be under scrutiny. 

Another specific target area for the OIG is home health telehealth services. See: Audit of Home Health Services Provided as Telehealth During the COVID-19 Public Health Emergency  As noted by the OIG, the final regulations allowing home health agencies to use telehealth services in conjunction with in-person visits specified that “the plan of care must include any provision of remote patient monitoring or other services furnished via telecommunications technology or audio-only technology, and that such services must be tied to patient-specific needs as identified in the comprehensive assessment.”  Furthermore, the regulations stated that telehealth services cannot substitute for a home visit.  The OIG states it will be evaluating home health services provided by agencies during the pandemic to determine whether the services were billed in accordance with Medicare requirements. 

If you are a health care provider delivering health care services via telehealth, there are some practical ways to prepare for increased auditing of telehealth services.  First, consider establishing a baseline of your current compliance with payor requirements by conducting an internal or external audit of your claims.  If you have the expertise in-house and feel confident of your understanding of the clinical, documentation, and technical aspects of utilizing telehealth, an internal audit may help you to understand if you have any audit vulnerabilities.  On the other hand, if you either lack the internal expertise to conduct an audit or you want to have a third party confirm your compliance, a well-structured external audit by a third-party consultant can be invaluable.  An auditor can help you explore whether your billing is in compliance with the clinical and technical expectations of the payors in question. 

Areas to explore during an audit include:  whether you have the appropriate documentation in the file to support time-based codes and/or the requisite level of decision making; whether your records meet the specific billing requirements for telehealth; whether your claims meet the specific payor’s specified technical requirements; and, whether there are potential individual provider issues, such as enrollment, licensing, and DEA registration requirements. 

In addition to conducting baseline audits, this is also a good time to review compliance programs, policies, and procedures to ensure the compliance program is effective and takes into account the nuances involved in providing telehealth services.  

If you are not conducting robust education for clinical and billing staff concerning the proper billing and coding for telehealth services, it is also time to start these educational programs. 

In summary, the rapid development and use of telehealth during the pandemic has led to a recognition of the value of telehealth, as well as the payors’ recognition of the need to oversee the integrity of the telehealth claims being billed.  If you are billing for telehealth services, it may be a great time to regroup and ensure your billing is compliant. These compliance measures will save you a lot of administrative time and money in the long run.

This is an article from a series on Effectively Responding to Payor Audits & Program Integrity Investigations.  Topics in this series include practical advice and legal developments for providers defending payor audits and investigations, plus articles concerning current audit and investigation targets and the various types of auditors reviewing claims and conducting investigations.  The Series covers topics of interest to all providers of health care services, including hospitals, hospices, home health agencies, skilled nursing facilities, DME suppliers, clinical laboratories, pharmacies, FQHCs, RHCs, ASCs, community mental health centers, physicians, therapists, and other health care facilities, entities, practitioners, and clinicians.

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