The federal government will audit Medicare payments for telehealth services. One focus is confirming that the patient was at an eligible site.

• Medicare is seeing more claims for telehealth services.

• There are gaps in the number of claims for distant sites and originating sites.

• The gaps may indicate that the originating site was ineligible.

Healthcare organizations offering telehealth services should expect more scrutiny from the federal government now that the Department of Health and Human Services (HHS) Office of Inspector General (OIG) has announced plans to review Medicare payments for telehealth services, seeking to confirm the patient was at an eligible originating site and that the statutory conditions for coverage were met.

“To support rural access to care, Medicare pays for telehealth services provided through live, interactive videoconferencing between a beneficiary located at a rural originating site and a practitioner located at a distant site,” OIG explains in a supplement to its 2017 Work Plan. “An eligible originating site must be the practitioner’s office or a specified medical facility, not a beneficiary’s home or office. We will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.”

Increased Scrutiny May Mean Greater Clarity

The increased scrutiny is not necessarily reason for concern, says Nathaniel M. Lacktman, JD, partner with the law firm of Foley & Lardner in Tampa, FL. Healthcare organizations should consider the audits one more reason to ensure compliance with the Medicare rules on telehealth, but the audit program is not expected to be particularly onerous or risky, he says.

Eventually, the OIG focus on telehealth compliance will yield clarification on any questions and make compliance easier, he says.

“We’re seeing a bit more growth and utilization of telehealth in the Medicare program, which clearly is lagging behind state Medicaid programs and commercial payers in the types of telehealth it covers,” Lacktman says. “Providers are getting more confident and submitting more claims to Medicare for those services, so that triggers a need for a review.”

Site Fees Not Always Clear

Medicare pays for telehealth services in two ways — the distant site fee, which covers the professional fee for the remote physician or nurse practitioner delivering the service, and the originating site fee, which reimburses the facility where the patient is located. Typically, the originating site fee is about $25.

HHS has clarified that it is not necessary that claims be filed for both reimbursement opportunities, Lacktman says. If a claim is filed for the distant site fee but not the originating site fee, Medicare still can pay the distant site fee.

For instance, the originating site may not file for reimbursement because the $25 is not worth the time and effort. But Medicare has noted a gap in the types of claims filed and theorized that some of those gaps may be due to the ineligibility of the originating site, such as the patient’s home. That would invalidate the claim for the distant site.

“That’s what the OIG audit is really intended to investigate,” Lacktman says. “They will be looking at the other requirements as well, but that gap in those types of claims is prompting their curiosity because the location of the patient is the one factor that is not obvious from the claims documentation.”

To help understand the telehealth requirements for Medicare, HHS offers a Telehealth Payment Eligibility Analyzer available online at: 

“Medicare providers should continue to bill Medicare for telehealth services that are covered, and they should make sure they fully understand the eligibility requirements,” Lacktman says. “This actually represents a growth for telehealth. Auditing the claims is a sign that Medicare is moving to embrace it more and bring telehealth more in to the mainstream.”


• Nathaniel M. Lacktman, JD, Partner, Foley & Lardner, Tampa, FL. Phone: (813) 225-4127. Email: nlacktman@foley.com.