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Fraud in Government Telehealth Programs: How to Report it Under the False Claims Act for a Whistleblower Reward

Posted  September 4, 2019

When patients are unable to see a doctor in person, technology can offer solutions. Telehealth or telemedicine is the provision of health services – including assessment, diagnosis, intervention, consultation, or supervision – across distance through the use of information technology. It can be especially valuable in rural areas, where specialty providers may not be available.

And its use has grown exponentially: Telehealth visits among rural Medicare beneficiaries jumped from just over 7,000 in 2004 to nearly 108,000 in 2013, and to over 275,000 in 2016.

As the use of telehealth has increased, so too has misuse of telehealth, including fraud in telehealth services. Whistleblowers with information about fraud in telehealth services may be able to make a report under the False Claims Act and be eligible to receive a whistleblower reward.

How Telehealth Works

A variety of government health plans reimburse telehealth services, including Medicare, the VA, TRICARE, Indian Health Services, and state Medicaid programs.

In the case of Medicare fee-for-service (Part B), telehealth services must be provided to an eligible beneficiary located at a certified rural originating site by a practitioner located at a distant site. Only certain types of services and certain categories of providers are included.

The Veterans Services Administration and TRICARE have their  own rules and do not require that beneficiaries be in a designated rural area, although types of services covered are restricted..

In FY 2018, only 45% of the VA’s 782,000 telemedicine users were in rural areas. In anticipation of greater demand, the VA requested $1.1 billion for telehealth services in their 2020 budget.

Fraud and Abuse in Telehealth

A recent investigation by the Dept. of Health and Human Service Office of the Inspector General found that nearly one third of the telehealth claims they examined did not meet Medicare requirements.

Beyond improper coding and billing for ineligible services, telemedicine is susceptible to other types of fraud:

Kickbacks – A $1.2 billion fraud case resulted in charges against five telemedicine companies that received illegal bribes from DME companies in exchange for referral of Medicare beneficiaries for unnecessary back, shoulder and wrist braces. TRICARE was the victim of a $65 million pharmacy telemedicine kickback scheme.

Rural Health Care Program Fraud – Eligible telehealth providers can receive financial assistance for video-conferencing, high-speed internet, and the construction of broadband networks. The FCC imposed a $18.7 million fine against a company that undermined the competitive bidding process and defrauded the Universal Service Fund Rural Health Care Program.

Fraud in telehealth will often go undetected unless it is discovered and reported by a whistleblower. In some circumstances, whistleblowers who come forward with their information to stop the wrongdoing may get an award from recovered funds by bringing a claim under the False Claims Act.

If you have information that a person or company is defrauding federal healthcare programs and would like to talk with us about whether you have a whistleblower case, please contact us confidentially.

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Tagged in: FCA Federal, Healthcare Fraud, Importance of Whistleblowers, Provider Fraud, Whistleblower Eligibility,