As telemedicine grows, fraud prevention offers intriguing side story

A couple weeks ago, I sat on my couch, staring at my ankle and mulling over my options. My problem wasn't serious. My ankle wasn't broken or sprained, which might warrant a trip to the emergency room. Instead, a skin irritation had grown into a sizeable rash now accompanied by swelling.

I reached for my phone and began typing in the address for WebMD, but thought better of it. More often than not, a 15-minute WebMD session provokes an undeniable urge to place an irrational, panic-induced call to 911. Quick, send an ambulance. This skin rash is life-threatening.

Unfortunately it was after 5 p.m. and my primary care physician was long gone. This left me with two options: Wait it out, or make the trip to an urgent care clinic. In my experience, urgent care had not always lived up to its name.

Eventually I relented and went to the clinic, waited a few hours, and saw a physician's assistant who referred me to the ER, where I waited another few hours before getting a prescription for antibiotics. All told, I spent about six hours waiting for medical care and charged more than $200 in copays to my credit card.

Days later, I heard a story on NPR about how UnitedHealth will start covering video chat visits to the doctor's office. Apps such as Doctor on Demand, NowClinic and Amwell will serve as the providers, allowing patients to log in from their phone and conference with a physician about health issues. This is a significant move--a large insurer throwing its weight behind telemedicine, which has struggled to achieve legitimacy in the payer market.

In the NPR story, a man named Eric Neiman describes his encounter with Doctor on Demand. He pulled to the side of the road to consult with a physician about his young daughter's eye irritation. A few minutes and a $40 copay later, he had a prescription for pink eye. Sitting in my own car, I couldn't help thinking about the time and money I could have saved with Doctor on Demand.

Telemedicine appears to be the future of medicine for those very reasons: Time and money. A 2014 survey by Towers Watson showed that 37 percent of employers expect to offer telemedicine consultations in 2015; another 34 percent are considering the option in 2016 and 2017. Other reports show that the telemedicine market will nearly double over the next five years, growing to about $5 billion, and saving patients approximately $100 per visit.  Last year, the Centers for Medicare & Medicaid Services (CMS) included a provision that would expand telemedicine coverage to include remote patient monitoring of chronic care management.

The prospect of telemedicine expansion appeals for patients, payers and employers, who could save as much as $6 billion a year, according to Towers Watson. The benefits, it seems, could be limitless.

But another thought crossed my mind moments after listening to the NPR story. How might this burgeoning industry contribute to potential fraud and abuse? If industries such as home care have become hotbeds of fraud, frequently billing for fictitious visits or services, it stands to reason that telemedicine encounters might face the same problems. If sham medical clinics are willing to bill millions for patient visits that never happened, how difficult will it be to prevent the same issues from cropping up in the telemedicine industry?

These questions remain largely unanswered for a couple of reasons. First, telemedicine regulations and payment structures are still developing, both federally and among private payers. Medicare reimbursement for telemedicine is still fairly strict, which makes it an undesirable target area for fraudsters. According to the Center for Telehealth & e-Health Law, 39 Medicaid programs offer some reimbursement for telehealth, mostly for behavioral health. Fifteen states currently mandate coverage for telehealth services.

"Although telehealth payment policies are evolving at a steady but somewhat erratic pace, limited reimbursement continues to be a major barrier to the expansion of telehealth," according to CTeL.

The Office of Inspector General (OIG) has provided some guidance, mostly in an Advisory Opinion published in 2011 that addresses anti-kickback considerations for stroke neurologists providing telemedicine services to community hospitals. The OIG said that providing telemedicine technology consultations to a community hospital, and accepting neurology transfers in return, would not result in administrative sanctions from the OIG.

Payment expansion feels imminent. The House Energy and Commerce Committee's 21st Century Cures legislation, released last week, requires CMS and the Medicare Payment Advisory Commission to conduct reports and studies on telemedicine expansion, but the American Telemedicine Association (ATA) is pushing for more "real action."

Don't underestimate the lobbying power of medical associations such as the ATA that will continue pushing for expanded reimbursement for telemedicine services. Although that expansion, both among federal programs and private payers, will make telemedicine more accessible, you can bet that it will attract fraudsters looking to make to make a dime off a new area of healthcare with innovative schemes that rival the technology itself.

As we've seen, the Whac-A-Mole approach is not effective in preventing fraud. The inevitable growth of this new technology requires a more diligent proactive strategy from the feds, as well as private insurers. That may involve collaborative efforts with apps such as Doctor on Demand to build in roadblocks to fraud, or better use of predictive analytics to stop unnecessary payments before they hit the bank account.

However it shakes out, it remains an interesting side story. Federal prosecutors are finally catching up with fraud hotspots across the country. As this new sector of medicine grows, so should our awareness of potential fraud concerns. Otherwise, the past is doomed to repeat itself.  - Evan (@HealthPayer)

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