Tech & Innovation in Healthcare

FBI faces new challenges when fighting telemedicine fraud.

Studies continue to show how popular and effective telehealth, or telemedicine, is as a healthcare option for certain providers and practices. However, some people use it as an opportunity to defraud the healthcare system.

Understand the different types of telehealth fraud and how the Federal Bureau of Investigation (FBI) is working to catch bad actors.

Widely Adopted Telehealth Use Created More Fraud Opportunities

Telehealth has been incredibly useful for providers during the COVID-19 public health emergency (PHE). The modality allows providers to deliver care and monitor conditions and treatment regimens safely without putting the provider or patient at risk for contracting a COVID-19 infection. Telehealth is also beneficial to patients who live in rural areas and would have to travel far distances to receive care.

However, some providers and practices have taken advantage of telehealth services and are using the technology to commit healthcare fraud. “You could say it’s a double-edge sword from a law enforcement perspective,” said Gregory Heeb, supervisory special agent and healthcare fraud unit chief of the FBI in the “FBI Healthcare Fraud Program Overview” session at AAPC’s HEALTHCON 2022 conference. “Telehealth has brought some new challenges to the way we investigate healthcare fraud. It’s brought us throughout the country, and sometimes, throughout the globe trying to track down a telehealth provider that might be facilitating fraud.”

Common types of telehealth fraud include:

• Upcoding: Exaggerating the amount of time spent with patients in addition to overstating the complexity of the encounter.
• Kickbacks: Offering financial incentives to deliver unnecessary medical testing. This may include ordering genetic testing, prescriptions, or other medical devices.
• Billing for services not rendered: Providers billing for telehealth appointments that didn’t occur, were negatively affected by a poor audio/video connection, or couldn’t take place due to other technological issues. Even if a well-intended attempt was made to provide services, if the patient is unable to benefit from the medical services, then they shouldn’t be billed.
• Misrepresenting services: Inaccurately reporting video consultations, telephone calls, and virtual check-ins to Medicare and other payers.

Telehealth Remains a Popular Healthcare Option

Before the PHE, most providers rarely used telehealth appointments, and Medicare and Medicaid more strictly assessed reimbursement for those appointments. Since March 2020, the Centers for Medicare and Medicaid Services (CMS) has offered select waivers and flexibilities for telehealth reimbursements due to the unprecedented conditions.

Telehealth doesn’t appear to be going away anytime soon. A 2021 survey found that 23.1 percent of respondents in the U.S. used telehealth services in the previous four weeks. Additionally, a Department of Health and Human Services (HHS) study found 63-fold increase in Medicare telehealth use in 2020. The study reported that 840,000 people used telehealth in 2019, but the share of Medicare telehealth visits in 2020 ballooned to 52.7 million people.

Understanding Healthcare Fraud in a New Package

The explosion of telehealth use since March 2020 has also resulted in significant healthcare fraud. “This won’t be shocking to anybody. Telehealth or telemedicine brings a whole new set of challenges for law enforcement,” Heeb said. He added that the FBI is seeing the same common schemes of healthcare fraud with different aspects to them.

Here are two recent examples of telemedicine fraud in the news:

In September 2021, the Department of Justice (DOJ) announced criminal charges against more than 130 defendants for their alleged participation in various healthcare fraud schemes totaling approximately $1.4 billion in alleged losses. Of the $1.4 billion, approximately $1.1 billion in fraud was allegedly committed using telemedicine.

In December 2021, a federal jury convicted two Florida defendants of conspiracy to commit healthcare fraud, multiple counts of mail fraud, and introduction of a misbranded drug into interstate commerce. During the scheme, the two defendants and another co-conspirator, employed a Florida telemarketer and directed them to use the telemarketing platform as a telemedicine service to contact consumers, mislead them into agreeing to accept prescriptions, and convince consumers to provide personal insurance information.

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