Fraud Detection Operation examines telehealth

The OIG Fraud Detection Operation (FDO) team identified three occupational therapy/physical therapy (OT/PT) service providers with claims indicating services were provided via telehealth. With the increase in telehealth as a service delivery vehicle since the COVID-19 pandemic began, the FDO team determined a review of billing from providers utilizing this option was appropriate. An FDO utilizes data points to review billing data to narrow areas of possible concern in the billing. Providers are allowed to provide and bill for certain OT/PT services utilizing telehealth; however, there have been reports that the services did not occur, or the time, duration and scope of the service did not meet the program policy and billing requirements. Policy requires providers must document and perform the service to the same level as they would in a face-to-face setting.

The record reviews for all three FDO-identified providers were completed in September, which resulted in a referral for a full investigation for one provider. A full investigation will allow for a broader look at the provider’s billing and documentation patterns to determine if a violation of Medicaid policies or rules has occurred.

Data analysts are also currently reviewing behavioral health services delivered during the COVID-19 pandemic and will also look at durable medical equipment and laboratory services in the next two quarters of the fiscal year.