Dozens of investigations have been conducted of fraud schemes involving companies that purported to provide telehealth, telemedicine, or telemarketing services (collectively, Telemedicine Companies) and exploited the growing acceptance and use of telehealth.
For example, in some of these fraud schemes, Telemedicine Companies intentionally paid physicians and nonphysician practitioners (collectively, Practitioners) kickbacks to generate orders or prescriptions for medically unnecessary durable medical equipment, genetic testing, wound care items, or prescription medications, resulting in submissions of fraudulent claims to Medicare, Medicaid, and other Federal health care programs.
These fraud schemes vary in design and operation. They have involved various individuals and types of entities, including international and domestic telemarketing call centers, staffing companies, Practitioners, marketers, brokers, and others.
One common element of these schemes is how Telemedicine Companies have used kickbacks to aggressively recruit and reward Practitioners for furthering the fraud schemes.
Generally, the Telemedicine Companies arrange with Practitioners to order or prescribe medically unnecessary items and services for individuals (referred to here as “purported patients”) who are solicited and recruited by Telemedicine Companies.
In many of these arrangements, Telemedicine Companies pay Practitioners in exchange for ordering or prescribing items or services:
- for purported patients with whom the Practitioners have limited, if any, interaction; and
- without regard to medical necessity. Such payments are sometimes described as payment per review, audit, consult, or assessment of medical charts.
Telemedicine Companies often tell Practitioners that they do not need to contact the purported patient or only need to speak to the patient by telephone.
In addition, Practitioners are not allowed to review the purported patient’s real medical records. Furthermore, the Telemedicine Company may direct Practitioners to order or prescribe a preselected item or service, regardless of medical necessity or clinical appropriateness.
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In many cases, the Telemedicine Company sells the order or prescription generated by Practitioners to other individuals or entities that then fraudulently bill for the unnecessary items and services.
These schemes raise fraud concerns because of the potential for considerable harm to Federal healthcare programs and their beneficiaries, which may include:
- an inappropriate increase in costs to Federal healthcare programs for medically unnecessary items and services and, in some instances, items and services a beneficiary never receives;
- potential to harm beneficiaries by, for example, providing medically unnecessary care, items that could harm a patient, or improperly delaying needed care; and
- corruption of medical decision-making.
The Health and Human Services Office of Inspector General encourages Practitioners to exercise caution and use heightened scrutiny when entering into arrangements with Telemedicine Companies that have one or more of the suspect characteristics as described below.
This Special Fraud Alert provides information to help Practitioners identify potentially suspect arrangements with Telemedicine Companies.
Based on OIG’s and DOJ’s enforcement experience, they have developed the below list of suspect characteristics related to Practitioner arrangements with Telemedicine Companies, which could suggest an arrangement that presents a heightened risk of fraud and abuse.
This list is illustrative, not exhaustive. The presence or absence of any of these factors is not determinative of whether a particular arrangement with a Telemedicine Company would be grounds for legal sanctions.
- The purported patients for whom the Practitioner orders or prescribes items or services were identified or recruited by the Telemedicine Company, telemarketing company, sales agent, recruiter, call center, health fair, or through the internet, television, or social media advertising for free or low out-of-pocket cost items or services.
- The Practitioner does not have sufficient contact with or information from the purported patient to meaningfully assess the medical necessity of the items or services ordered or prescribed.
- The Telemedicine Company compensates the Practitioner based on the volume of items or services ordered or prescribed, which may be characterized to the Practitioner as compensation based on the number of purported medical records that the Practitioner reviewed.
- The Telemedicine Company only furnishes items and services to Federal health care program beneficiaries and does not accept insurance from any other payor.
- The Telemedicine Company claims to only furnish items and services to individuals who are not Federal health care program beneficiaries but may, in fact, bill Federal health care programs.
- The Telemedicine Company only furnishes one product or a single class of products (e.g., durable medical equipment, genetic testing, diabetic supplies, or various prescription creams), potentially restricting a Practitioner’s treating options to a predetermined course of treatment.
- The Telemedicine Company does not expect Practitioners (or another Practitioner) to follow up with purported patients, nor does it provide Practitioners with the information required to follow up with purported patients (e.g., the Telemedicine Company does not require Practitioners to discuss genetic testing results with each purported patient).
Practitioners who enter into arrangements with Telemedicine Companies in which one or more of these suspect characteristics are present should exercise care and may face criminal, civil, or administrative liability depending on the facts and circumstances. – Source
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