Tips for Navigating Telehealth Expansion and Reimbursement

During the COVID-19 pandemic, the government made it easier for urgent care providers to connect with their patients through telehealth expansion. They removed some regulatory roadblocks, but they also made many changes and updates often to the telehealth services rules causing both provider consternation and billing mishaps. In this month’s “3 Things to Know About RCM,” we’ll update the state of telehealth, common errors in Medicare Part B claims, and provide some guidance on reporting HIPAA breaches.

Telehealth Momentum and Compliance

Throughout the pandemic, telehealth became an integral piece for solving the COVID-19 puzzle for urgent care providers. To help providers respond to the growing number of patients, the feds issued 1135 waivers and other flexibilities — including expanding telehealth services offerings.

While expansion and flexibility were welcomed by urgent care, new codes and regulations also created confusion—and ultimately, rejected claims. Industry data suggests a 60-70 percent error rate on telehealth service claims.

Two of the primary sources of errors are:

1. Coding audio-only visits as telehealth visits.
2. Insuring “approved providers” are administering telehealth visits (based on Centers for Medicaid & Medicare Service guidelines).

Telehealth refers to health services that use audio and video components to connect with patients.

The significant drop in COVID-19 infections doesn’t mean the Public Health Emergency or the need for virtual visits will go away. Experts anticipate that provider’s reliance on telehealth and the convenience it affords patients will increase over time.

The Biden Administration expects waivers and regulatory relief to last all year. According to HHS Acting Secretary Norris Cochran in a Jan. 22 letter to state governors, “To assure you of our commitment to the ongoing response, we have determined that the PHE will likely remain in place for the entirety of 2021.”

The letter specifically mentions telehealth as a tool to increase access to healthcare during a PHE.

If you’re uncertain about which services CMS (and most other commercial carriers) allow to be conducted via audio-only interactions, you can check current guidance. CMS has a list of which E/M codes can be furnished via telehealth versus audio-only services, both during the PHE and generally.

Both the Department of Health and Human Services (HHS) and CMS have recently updated their telehealth services guidance. See COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing and the HHS’ patient and provider assistance, facilitated in coordination with the Health Resources & Services Administration (HRSA) for additional information.

In addition to cleaning up telemedicine claims, providers should expect to see more telehealth audits. The HHS Office of Inspector General (OIG) added telehealth services used during the COVID-19 PHE to its audit agenda. According to OIG sources, “”We will report as overpayments any services that were improperly billed. We will make appropriate recommendations to CMS based on the results of our review.”

For more information, see the OIG Work Plan and recently added action items.

Medicare Part B Error Rate Spiked in 2020

Designed to determine if Medicare contractors are processing and paying claims correctly, CMS’ Comprehensive Error Rate Testing (CERT) program, offers statistics and methodologies on the biggest errors found in Medicare FFS claims as well as what caused the improperly paid charges.

On Dec. 21, 2020, CMS released the 2020 Medicare FFS Supplemental Improper Payment Data as part of its CERT program. The CERT data showed Medicare Part B’s portion of the improper payment rate at 32.8 percent of the overall amount — an increase from the 2019 rate of 29.9 percent.

The CERT results highlight the various insufficient documentation issues that hiked up Part B’s portion of the error rate. Missing or inadequate records accounted for a staggering 74.1 percent of Part B’s documentation woes, while missing or inadequate orders was the second biggest issue at 20.2 percent.

The report identifies the following problem areas under insufficient documentation that Part B practices struggle with:

• Documentation to support medical necessity was missing or inadequate.
• Notes to support services or a specific code for payment were missing or inadequate.
• Providers’ orders or even intents to order were missing from documentation.

While this report covers only Medicare/Medicaid Part B claims, it indicates a documentation challenge for the healthcare industry as a whole, as payers generally adhere to CMS guidelines. To be sure your claims are efficiently and appropriately process, be sure everyone on your urgent care team understands the importance of full and appropriate documentation to prove medical necessity.

Take note: Although CMS did halt the CERT program temporarily due to the COVID-19 public health emergency (PHE), it reinstated reviews in August 2020 for reporting years (RYs) 2021 and 2022, according to online guidance.

All phone calls and documentation requests going forward will be for RY 2021 and RY 2022 CERT audits, CMS says.

For more information, access helpful CMS provider tools.

Stay on Top of HIPAA Breach Reporting

As reported earlier, data security incidents and privacy issues didn’t stop with the pandemic”in fact, it has magnified them.

Security issues often lead to HIPAA breaches that must be reported. As a best practice, report security breaches relating to protected health information (PHI) to the Department of Health and Human Services (HHS) Secretary as soon as they’re discovered.

A HIPAA breach is any acquisition, access, use, or disclosure in violation of the privacy rule. If you uncover a HIPAA breach in your practice, there are different timelines for reporting to HHS. The larger the breach the shorter the turnaround time to report the details.

Use this resource to learn more about the timelines and access current guidance.

Interested in more urgent care tips, best practices, and industry updates? Check out our January  and February installments.

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