Telehealth Expansion Gets Bipartisan Congressional Support

July 2014 has brought a lot of activity toward expanding telehealth services to improve access to health care for seniors and others and lower the costs of health care for federal health care programs. Members of both houses of Congress and both political parties have introduced bills that would require Medicare to expand telehealth services provided to Medicare and Medicaid beneficiaries. Moreover, CMS’ 2015 Physician Fee Schedule Proposed rule includes a proposal to add annual wellness visits, psychotherapy services, and prolonged evaluation and management services to the Medicare telehealth benefit. In announcing its appreciation for the efforts of legislators to push for improvements in telemedicine coverage, the American Telemedicine Association (ATA) stated that the “bills are instrumental in demonstrating widespread congressional support.”

Telehealth Parity Act of 2014 

On July 31, 2014, House of Representatives members Mike Thompson (D-Calif.), Gregg Harper (R-Mississippi), and Peter Welch (D-Vermont) introduced the Medicare Telehealth Parity Act of 2014 (HR 5380) (Discussion Draft) , which “creates a [three] phase approach over four years to expand coverage of telemedicine-provided services and removes arbitrary barriers that limit access to services for Medicare beneficiaries,” according to an ATA press release. Thompson explained that the bill puts telehealth services under Medicare on the path toward parity with in-person health care visits. The legislation has been referred to the House Energy and Commerce Committee and the House Committee on Ways and Means.

The phase-in begins in rural areas and gradually removes geographic restrictions to patient care. The bill also provides for telehealth services furnished by diabetes educators as well as outpatient therapists, including speech language therapist, audiologists, respiratory therapists, and physical therapists; allows remote patient management services for chronic health conditions such as diabetes, congestive heart failure, and chronic obstructive pulmonary disease, including patient monitoring, patient training, clinical observation, assessment, treatment and other services; and expands home telehealth, hospice, and home dialysis.  The bill requires Government Accountability Office (GAO) to conduct a study of the effectiveness of remote patient monitoring on decreasing hospital readmissions for the chronic conditions included in the bill and the savings to Medicare as well as the implications of greater use of patient monitoring with respect to payment and delivery system transformations. The bill is discussed in more detail in a post by Bryant Storm titled, “Bill Would Stretch Telemedicine to Physical Therapy, Bigger Populations.”

Telehealth Enhancement Act of 2014

The Telehealth Enhancement Act of 2014 (S. 2662), which was introduced by Senators Thad Cochran (R. Mississippi) and Roger Wicker (R-Mississippi), would expand the use of telehealth technology to improve health care for seniors and other patients in underserved areas as well as help lower health care costs. The legislation would waive statutory Medicare restrictions on telehealth services to encourage greater use of telehealth technologies and would extend telehealth coverage to all critical access and sole-community hospitals regardless of metropolitan status. The legislation also covers home-based video services for hospice care, home dialysis, and homebound seniors. Medicare home health payments would be adjusted. In addition, the bill would allow states to modify Medicaid coverage to include telehealth services for women with high-risk pregnancies. The bill has been referred to the Senate Finance Committee. According to the ATA, the bill “includes several provisions that may see significant budget savings and build on recent payment innovations such as accountable care organizations and other incremental budget-sensitive proposals.”

This Senate bill is a companion to legislation introduced by Harper, Thompson, Welch, and Devin Nunes (R-Calif.) last year, known as the Telehealth Enhancement Act of 2013 (HR3306). Many of the provisions of HR 3306 are reflected in S. 2662. The ATA Hub summarized the provisions of HR 3306, stating that such provisions include incentive for reducing hospital readmissions, advancing a health home approach as found in the Medicaid program, care coordination for chronic illness such as Parkinson’s, flexibility for accountable care organizations to offer telehealth services, expansion of geographic locations, coverage of home-based video services, and coverage of Medicaid telehealth services for high-risk pregnancies. HR 3306 is pending in the House Ways and Means Committee and House Energy and Compliance Commerce. According to Wicker, “Telehealth cuts down travel time and increases access to specialists for residents in many rural areas who do not live near these essential health care resources.”

CMS Proposed Rule

CMS proposed to add the following services to the list of services that can be furnished to Medicare beneficiaries under the telehealth benefit: annual wellness visits, including a personalized prevention plan of service, initial visit, and subsequent visit; psychotherapy services, including family psychotherapy with and without patient present; and prolonged evaluation and management services requiring direct patient contact beyond the usual service. CMS found that these services meet the criteria for being on the Medicare telehealth list and are sufficiently similar to psychiatric diagnostic procedures or office outpatient visits currently on the telehealth list to qualify for coverage.


“Telehealth  is one of the most promising aspects of the health care field,” according to Harper. The use of telehealth technology and services may be the answer for improving access to health for seniors and others in underserved areas and lowering health care costs; however, Wayne Caswell, member of ATA and Founder of Modern Health Talk, sees this as “a step in the right direction” but “just a baby step” and noted that he thinks “much more is needed.”  In an article, written in response to the introduction of the Telehealth Enhancement Act of 2013 bill, Caswell cautioned that the telehealth bills introduced in Congress may get resistance from states seeking to “preserve the status quo and the authority of state medical boards.” Other risks related to the expansion of telemedicine services such as privacy, confidentiality, credentialing, and failure of technology for health care providers are discussed in the post, “Growth of Telemediccine Services Brings the Need to Address Associated Risk.

Kusserow’s Corner: House Hearing on Medicare Fraud and Abuse

The U.S. House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing on “Medicare Program Integrity: Screening Out Errors, Fraud, and Abuse.” During the hearing, subcommittee members heard testimony from CMS Deputy Administrator and Director of the Center for Program Integrity Dr. Shantanu Agrawal, HHS Office of Inspector General (OIG) Deputy Inspector General for Investigations Gary Cantrell, and Government Accountability Office (GAO) Director of Health Care Kathleen M. King.

CMS Testimony

The CMS testimony revolved around how it is applying three operational principles to guide all of its initiatives: (1) aiming to achieve operational excellence in addressing the full spectrum of integrity causes, in taking swift administrative actions, and in the performance of audits, investigations and payment oversight; (2) providing leadership and coordination in program integrity efforts across the health care system; and (3) focusing on impacting the cost and appropriateness of care across health care programs. Some of CMS’s efforts to reduce fraud, waste and abuse were noted, including: (1) strengthening provider enrollment; (2) ensuring proper and accurate claims payment; (3) facilitating leadership and coordination across the health care system; and (4) improving payment data transparency.

CMS acknowledged the failure to meet its target goal of a reduced improper payment rate for Medicare fee-for-service, and that the improper payment rate had actually worsened over the last fiscal year. CMS noted that it recovered about $19.2 billion in fraudulent payments over the past five years, including $210 million through a new system that uses analytics to probe billing patterns; however, the recovered sum is dwarfed by the size of the problem, projected to be up to $50 billion a year.

The subcommittee cited one news outlet that reported that several doctors who had lost a medical license were still able to bill the Medicare program for millions of dollars. In addition, it noted that at least 14 individuals convicted of FDA-related crimes and debarred by the FDA do not appear to be excluded from the Medicare program; six doctors debarred by the FDA were paid over $1 million in Medicare payments in 2012. Another issue raised in the hearing was that a Medicare card has the patient’s social security number (SSN), creating serious risk of identity theft. Both the GAO and OIG identified fixing this SSN issue as an important step in preventing Medicare fraud.

GAO Testimony

The GAO testimony spoke to their strategies to combat fraud through examining: (1) the ability of CMS’ information system to prevent and detect enrollment of ineligible or fraudulent Medicare providers and suppliers; (2) the possible use of electronic-card technologies; (3) the oversight of program integrity efforts for prescription drugs; and (4) the oversight of certain contractors who conduct post-payment claims reviews. The GAO has focused on the following strategies: (1) provider and supplier enrollment; (2) prepayment and post payment claims review; and (3) addressing identified vulnerabilities. Based upon its work, the GAO recommended:

  • Requiring additional provider and supplier disclosures of information;
  • Establishing core elements for provider and supplier compliance programs as authorized in the Patient Protection and Affordable Care Act (ACA);
  • Increasing use of prepayment edits to help prevent improper payments;
  • Improving oversight of the information systems analysts use to identify claims for post payment, as well as the contractors responsible for the reviews;
  • Implementing mechanisms to resolve vulnerabilities that could cause improper payments; and
  • Removing SSNs from beneficiaries’ Medicare cards to help prevent identify theft.

OIG Testimony

The OIG testimony provided an overview of current health care fraud trends and challenges that impede effective oversight, as well as recommendations on how to address such trends and challenges that could result in billions of dollars being saved, along with a more efficient and effective programs. These included:

  • Providing the OIG with authority to execute federal warrants for the seizure of assets for forfeiture to curb the profitability of healthcare fraud, which will exert a deterrent effect.
  • Removing SSNs from Medicare cards to help protect the personally identifiable information of Medicare beneficiaries.
  • Strengthening the Medicare contractor’s monitoring of pharmacies and its ability to identify for further review of pharmacies with questionable billing patterns.
  • Requiring Part D plans to verify that prescribers have the authority to prescribe.
  • Increasing monitoring of Medicare claims for home health services.
  • Creating a standardized form to ensure better compliance with the face-to-face encounter documentation requirements for home health agencies (HHAs).
  • Implementing the surety bond requirement for HHAs.
  • Monitor hospices that depend heavily on nursing facility residents.
  • Modifying the hospice payment system for care in nursing facilities, seeking statutory authority if necessary.
  • Taking action to provide States with data for identifying overpayments for physician certification statement (PCS) claims when beneficiaries are receiving institutional care paid for by Medicare or Medicaid.
  • Mandating the use of the audit log feature in all electronic health records (EHRs).
  • Working with contractors to identify best practices and develop guidance and tools for detecting fraud associated with EHRs, with specific guidance to address documentation and electronic signatures in EHRs.
  • Amending regulations to require Medicare Advantage and Part D plans to report to CMS, or its designee, their identification of and response to incidents of potential fraud and abuse.
  • Establishing a deadline for when complete, accurate, and timely Transformed Medical Statistical Information System (T-MSIS) data will be available.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.

Kusserow’s Corner: CMS Efforts Have Led to $19 Billion in Fraud Recoveries

The House Ways and Means Health Subcommittee held a hearing on May 20 on oversight of the Medicare program, specifically targeting waste, fraud, and abuse. The subject was “CMS Efforts to Reduce Improper Payments in the Medicare Program.” The subcommittee called three witnesses to discuss action against Medicare fraud. Gloria Jarmon, the CMS Office of Inspector General (OIG) Deputy Inspector General for Audit Service, spoke about the need for CMS to reduce improper payments and improve oversight of contractors. Kathleen King, the Director of Health for the Government Accountability Office (GAO), spoke about the need for further action at CMS on implementing strategies developed by the GAO. Finally, Dr. Shantanu Agrawal, the new Deputy Administrator and Director of the Center for Program Integrity at CMS, responded to criticism that the agency has not made sufficient progress in fighting Medicare fraud, waste, and abuse. This hearing followed a similar one before the Special Committee on Aging.

Dr. Agrawal stated that fraud-fighting efforts over the last five years have led to $19 billion in recoveries, up from $9.4 billion in the prior five years. The return on investment for this program has been $8.10 for every dollar spent. To achieve these results, CMS used a multi-faceted approach to target all causes of waste, abuse, and fraud by working closely with law enforcement agencies, especially through the Health Care Fraud and Abuse Control (CHFAC) program, which resulted in recoveries of $4.3 billion dollars. The areas of fraud and abuse that were highlighted in the testimony included the following:

  • Home health, where under new authorities provided by the Affordable Care Act, CMS moved to have moratoria on home health agencies in seven metropolitan areas. As reported extensively in this blog, there have been proportionately more enforcement actions in this sector than any other. It is also a major enforcement issue at the state level, where nearly 40 percent of all prosecutions by the state Medicaid fraud units involved home health.
  • CMS has labeled the Medicare fee-for-service as “high risk,” due to the sheer volume and complexity of the program, which includes 1.5 million providers that service 54 million beneficiaries. The vast majority of improper payments in the program are either the result of inadequate documentation for services billed or documentation that did not support the services as being medically necessary. A free webinar on June 5, presented by Dr. Cornelia Dorfschmid, focuses on this subject.
  • Durable medical equipment (DME) was also cited as high risk for fraud and abuse. One example given involved powered mobility devices, where CMS found over 80 percent of claims did not meet coverage requirements.
  • The testimony also cited the actions of the Recovery Audits, which has returned over $7.4 billion to Medicare.

Dr. Agrawal faced tough questions, with members of both parties showing irritation with CMS by their questions and comments. Committee members called for greater commitment to tackling fraud. Subcommittee Chairman Kevin Brady ended the hearing with a pledge to introduce legislation to address the problem, saying that a recent report revealed that fraud costs Medicare more than $50 billion annually.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow’s Corner Newsletter

Copyright © 2014 Strategic Management Services, LLC. Published with permission.

Doctor Payment Data Will Enhance Fraud Investigations

The release of Medicare payment data has already identified numeorus doctors who continue to recieve payments from Medicare even though they have been previoulsy discplined and are therefore ineligible to participate in the Medicare program.  Many are questioning why such discoveries have been made so easily by media sources with access to little data while the federal government spends billions these entities to find individuals who are defrauding the Medicare program.  The answer maybe as simple as that there is so much fraud and abuse going on, why does it matter how fradulent individuals are caught just as long as they are.  The main point is that the release of payment data will make it even easier for federal and state fraud investigators to identify and further investigate individuals with unusual billing practices or who should not even be receiving any federal reimbursement at all.

High paid physicians. Eight physicians were recently identified by Businessweek who billed more than $7 million during 2012 to Medicare while their medical licenses were suspended,  expired, or revoked. In some instances, the magazine reported that doctors who had their license suspeneded or revoked in one state while they had a license in another state used the other state’s license to qualify for Medicare payments.  The Businessweek article noted that many had their licenses revoked or suspended for gross malpractice, battery or violating prescription drug laws.

The New York times reported that in 2012 about two percent of doctors received approximately $15 billion from Medicare or roughly one-fourth of the $77 billion paid to doctors that year. The same article went on to identify 100 doctors who recieved a total of $610 million in 2012.  This article did not claim that any Medicare payments were improper, and stated that some of these amounts included very expensive drugs.  The New York Times article did point out that fraud invesitgators across the country now have a treasure trove of data available to examine and help identify physicians and others who are billing in execess of other professionals or who may not be licensed at all.  The New York Times provided a look-up tool so you can see how much any particular doctor has received from Medicare.

Program integrity. The level of fraud and abuse against the Medicare program is unknown, but is thought to be quite substantial. One estimate by former CMS Administrator Donald Berwick is that the total amount of fraud against Medicare and Medicaid is between $30 billion and $98 billion a year.   Because this number is difficult to determine, the Government Accountability Office (GAO) continues to list Medicare as a program that is at high risk for fraud and abuse;  a description that the GAO has attributed to Medicare since 1990.

In 2013, the federal government spent $1.5 billion fighting health care fraud and abuse while recovering  $4.3 billion  from health care fraud settlments and court judgements, according to the Health Care Fraud and Abuse Control Program’s Annual Report for Fiscal Year 2013.  Increased efforts to reduce fraud and abuse was a part of the Affordable Care Act (ACA) (P.L. 111-148). Since 2011, 17,000 providers have been prohibited from billing Medicare as a result of an ACA requirement that all 1.5 million providers and suppliers be rescreened, according to the testimony of Dr. Shantanu Agrawal, Deputy Administrator and Director of CMS’ Center for Program Integrity delivered to  before the Senate’s Select Committee on Agining in March 2014.  The rescreening found providers who were ineligible to participate in Medicare because they had felony convicitions, did not have the appropriate medical license, or had the wrong address on file.  In addition 260,000 suppliers and providers had their participation in Medicare revoked for not responding at all to the request for the rescreening.

The release of the amount paid to physicians by Medicare should increase the success of  fraud investigators who no doubt will follow the lead of journalist in identifying irregular billing patterns and people who do not meet the requirements to bill Medicare at all.