Beware: Telemedicine Non-Compliance Will Drain Your Hospital’s Coffers


Your hospital’s claims for telemedicine services are coming under fire, and you could soon see a significant crackdown on your compliance efforts. Get ready for the Centers for Medicare & Medicaid Services (CMS) to change the rules of the game for nabbing telehealth reimbursement.

Watch out: More than 70 percent of providers are now using telehealth services, but serious deficiencies exist in telemedicine contracts, hospital compliance guru Sue Dill Calloway explains in ProfEdOnDemand webinar, “CMS Hospital CoP and TJC Telemedicine Standards: Telemedicine Credentialing and Privileging.” And now, you’ll start seeing a big impact on your Medicare reimbursement if you’re not complying with CMS’ telemedicine requirements.

Avoid 6 Compliance Pitfalls

A recent report by the HHS Office of Inspector General (OIG) discovered that CMS paid for telehealth services that failed to meet Medicare requirements. From studying a sample of telehealth claims, the OIG found that Medicare should not have paid nearly one-third of them – accounting for approximately $3.7 million in payments to practitioners.

Mistakes: Specifically, the OIG found that the sampled claims failed to meet Medicare requirements because:

  • The beneficiaries received services at non-rural originating sites;
  • Ineligible institutions billed the claims;
  • The claims were for services provided to beneficiaries at unauthorized originating sites, such as at the patient’s home or at an independent renal dialysis facility;
  • The services were provided by an unallowable means of communication;
  • The claims were for a non-covered service; and
  • The services were provided by a physician located outside the United States.

Why? Lack of oversight, failure to implement claim edits, and practitioners’ lack of knowledge of Medicare telehealth requirements all led to the large number of faulty claims, the OIG said. The OIG’s report offered up three recommendations for CMS:

  1. Conduct periodic post-payment reviews to disallow payments for errors when telehealth claim edits cannot be implemented;
  2. Work with Medicare contractors to implement all telehealth claim edits; and
  3. Offer education and training to practitioners on Medicare telehealth requirements.

Launch 5 Telemedicine Program Elements

Impact: If your hospital bills Medicare for telehealth services, you should prepare to face review of your claims to confirm the patient was at an eligible originating site and that your claims met the statutory conditions for coverage, according to a Foley & Lardner LLP blog posting by partner attorney Nathaniel Lacktman.

Scrutinize your telehealth program and claims to ensure you’re complying with Medicare requirements, including coverage, coding, and documentation rules.

There are five basic elements of providing (and obtaining Medicare reimbursement for) telehealth services, according to Healthcare Compliance Pros:

  1. Policies and Procedures – These should include providing telehealth services, to help your organization, providers, and employees to make the right decisions and ensure activities comply with laws.
  2. Scope of Services – Define what services you can provide remotely, considering the CMS Conditions of Participation (CoP) for your facility type.
  3. Safe Communication Methods – Make sure the technology you use to provide telehealth services complies with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) requirements.
  4. Consent – You must provide patients with information on the risks and benefits of telemedicine services, and you must obtain and document their official consent.
  5. Accurate Documentation – Your documentation of telehealth services must be detailed, accurate, and thorough.

Do Telemedicine Credentialing by Proxy

Telemedicine credentialing has also become a significant issue. Many providers still use the traditional “primary source verification” process to credential physicians, instead of the streamlined credentialing by proxy process that both CMS and The Joint Commission (TJC) offer, noted Lacktman in a separate blog article on the proxy topic.

How it works: Credentialing by proxy allows the hospital receiving the telemedicine services – the “originating site” – to rely on the privileging and credentialing decisions made by the hospital or entity providing the telemedicine services, Lacktman explained. The providing entity is also known as the Distant Site Hospital (DSH) or Distant Site Telemedicine Entity (DSTE).

So if you’re still doing credentialing the old-fashioned way, consider taking advantage of the streamlined credentialing process for the receiving hospital and DSH or DSTE. You can use telemedicine more efficiently and comply with the CoP standards without incurring the full administrative burden that you would by using the traditional credentialing process, Lacktman pointed out.

Follow the Reimbursement Rules

Although the recently signed Bipartisan Budget Act will remove some telehealth limitations in 2019, Lacktman stated, the current five main conditions for coverage under Medicare are:

  1. The beneficiary is located in a qualifying rural area;
  2. The beneficiary is located in one of eight qualifying originating sites;
  3. One of 10 distant site practitioners eligible to furnish and receive Medicare payment for telehealth services provide the services;
  4. The beneficiary and distant site practitioner communicate via an interactive audio and video telecommunications system that provides real-time communication; and
  5. The Current Procedural Terminology (CPT) and/or Healthcare Common Procedure Coding System (HCPCS) code for the service itself is named on the list of covered Medicare telehealth services for the current year.

Bottom line: When billing for telemedicine services, you must comply with the CoP standards not only under CMS, but also from The Joint Commission, Calloway warns. Keep up on the changes and take care to steer clear of deficiencies in all your telemedicine contracts and your telehealth program as a whole.

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