The World of Coding and Medical Billing Fraud – Part 5: The Rise and Risk of Telemedicine

by Andrea Vieten
stethoscope on laptop keyboard with screen showing telemedicine
Header photo: Getty Images

Telemedicine has been aound for years, but it was never extensively used. COVID-19 has caused a massive acceleration in its use. Figures have risen from the single-digit range to 70-80% of all exams performed in just a short time.

While in the past telemedicine had been used for only a limited form of health care treatments, today it is an irreplaceable means of health care delivery for millions of people worldwide. And most likely, telemedicine will continue to play an essential and strong role even after the end of the pandemic.

Telemedicine offers positive healthcare benefits. Video and audio sessions with doctors and providers offer an enormous convenience and facilitation to consumers – no waiting times in overcrowded waiting rooms, no risk of infection and disease transmission are just two advantages that come with telemedicine.

But the rise of telemedicine has another side that needs to be considered and monitored closely. Scammers have already identified the possibilities of committing fraud and stealing millions of dollars from the health care system. As if this was not enough, these new scams pose tremendous dangers for consumers as bad actors begin creating companies with the sole purpose of committing telemed fraud.

As part of the Fraud Fact Friday series, our medical billing experts, Tami Rockholt and Mike Fossey, elaborate on the effects of COVID-19 and the current rapid rise of telemedicine.

RiskShield by INFORM helps carriers avoid unnecessary payouts and detect scams by automatically scoring incoming bills and alerting coding errors and potential fraud. For example, it applies red flags for unlisted codes or for providers which are new to the patient that are billing a telemed code for the very first treatment.

RiskShield also highlights inconsistencies within the billing and coding, for example, CPT codes that are not consistent with a telemed visit, such as the high-level Evaluation & Management codes 99204; 99205; 99214; and 99215. These CPT codes indicate more severe injuries that require a thorough exam and, thus, are in contradiction with a telemedicine visit.

Using a sophisticated profiling technology, RiskShield is capable of detecting outliers such as charges that exceed the usual amount billed by providers. Currently, within the hype of COVID-19 and telemedicine, codes are being billed with charges exceeding the average of comparable treatments by a factor of 5.

RiskShield bases the evaluation of medical bills on the broad picture, not only considering the lines of one bill but all lines billed in the claim. RiskShield can easily detect encoding issues such as unbundling of services, e.g., the often applied unbundling of both radiological and laboratory codes.

RiskShield also offers textual analysis to detect chart notes that resemble cloning, the copying and pasting of prior chart notes. For example, a telemed doctor cannot listen to bowel tones or breath sounds through a telehealth visit.

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About the author

  • Andrea Vieten

    As a Senior Business Consultant at INFORM GmbH, Andrea Vieten has been responsible for managing global implementation projects in the financial industry. With more than 10 years of experience, she has consulted and guided many financial institutions to the successful implementation of intelligent decision systems in the areas of risk, processes and compliance.

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