Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks
WHAT IS THE TOOLKIT?
This toolkit provides detailed information on methods to analyze telehealth claims to identify program integrity risks associated with telehealth services. It is based on the methodology that the Office of Inspector General (OIG) developed for the report Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks (OEI-02-20-00720), which identified Medicare providers whose billing for telehealth services poses a high risk to Medicare. To address this risk, OIG called for targeted oversight of telehealth services.
This toolkit is intended to assist public and private sector partners—such as Medicare Advantage plan sponsors, private health plans, State Medicaid Fraud Control Units, and other Federal health care agencies—in analyzing their own telehealth claims data to assess program integrity risks in their programs.
Gaining a better understanding of the program integrity risks associated with telehealth services can help policymakers and stakeholders develop necessary safeguards and address individual cases of potential fraud, waste, and abuse. Doing so will help ensure that the benefits of telehealth are realized while minimizing risk in an effective and efficient manner.
WHY DID OIG CREATE THE TOOLKIT?
The COVID-19 pandemic changed how patients visit and interact with their health care providers. The use of telehealth services grew dramatically during the first year of the pandemic and is now an important part of our health care system. Notably, Medicare beneficiaries used 88 times more telehealth services during the first year of the pandemic than in the year prior, with more than 2 in 5 Medicare beneficiaries using telehealth services in that year. Medicaid and private health plans also experienced exponential growth in the use of telehealth. In addition, certain groups, including those in medically underserved populations—such as Hispanic beneficiaries—were more likely to use telehealth than were other groups in Medicare.
However, along with the dramatic increases in use there have been concerns about fraud, waste, and abuse. Most recently, as part of the extension of telehealth in Medicare, lawmakers highlighted the need for further study on telehealth and Medicare program integrity.
As one of the lead Federal agencies fighting health care fraud, OIG is committed to supporting public and private partners in their efforts. In response to requests from stakeholders, OIG is providing this toolkit as an additional resource to support the oversight of telehealth. Through the use of proactive, data-driven analyses, including measures such as those detailed in this toolkit, public and private partners can more effectively identify potential fraud, waste, and abuse schemes in their health care programs.
WHAT DOES THE TOOLKIT INCLUDE?
The goal of this toolkit is to provide an approach to analyzing claims data for telehealth to identify areas in which additional safeguards may be necessary. The analysis can also help identify providers whose billing may pose a risk and warrant further scrutiny.
The toolkit includes detailed descriptions of seven data analysis measures that can be applied to the user's own data. Users can also modify the measures to meet their individual needs, such as identifying providers at varying levels of risk.
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.