The following is a guest article by Mandy Fogle, Healthcare Value Engineering at Shift Technology.
Telehealth is becoming the future of healthcare delivery across the globe. Traditional office visits are becoming a way of the past. Since the COVID pandemic began, healthcare has never had further reach of accessibility.
This type of delivery opens healthcare to more individuals who otherwise would not have been able to seek treatment before. Providers are now a phone call or an email away, and can reach patients even if they’re homebound or living in a rural area.
While health plans are embracing the ease of providing services to their members, telehealth is increasing challenges around improper payments. As a result, there’s a wide open field that allows bad actors plenty of leeway. New types of fraud are continually emerging, and it’s also become harder to uncover with traditional approaches.
What are the Challenges Raised by this Expanded Access to Healthcare?
The telehealth market is growing at a significant rate, and fraud is continuing to grow with it. For example telehealth utilization increased 63x (in Medicare alone!) between the beginning of 2019 and the end of 2020. Additionally, an Assistant Secretary for Planning and Evaluation report found that Medicare visits conducted through telehealth skyrocketed from approximately 840,000 in 2019 to 52.7 million.
Telemarketers are jumping on the opportunity to take advantage of vulnerable Medicare and Medicaid individuals – masking themselves as telemedicine providers. The healthcare industry has seen fraud cases continuing to increase and evolve, with one major recent example taking the form of a $1.2 billion USD case involving 36 individuals.
In the example above, various telemarketers conspired with medical practitioners to order unnecessary genetic tests and medical equipment. Marketers would call unsuspecting patients and ask them if they’d like certain tests – when they said “yes,” corrupt practitioners would then order the unnecessary procedures and bill the government.
This kind of fraud isn’t new, but the explosion in telehealth as a whole has made it much more common. Startup costs are low enough that it’s relatively easy to start a fly-by-night organization selling durable medical equipment using telemarketing tactics – easy enough that both new entrants and existing fraud networks are taking advantage of the opportunity.
What may be even more concerning, however, is the appearance of completely novel forms of fraud, invisible to today’s detection capabilities.
Is Telehealth Fraud Getting Harder to Identify?
It used to be that if a provider in Connecticut wrote a prescription for a patient visiting California, this would be considered suspicious behavior. With the advent of telehealth, however, this kind of provider-patient relationship is no longer considered an anomaly on its own. Payers need to consider additional data sources and contextual clues to confirm an allegation.
With telehealth, visits between prescribers and patients can take place over phone, video call or even through member portals. Patients now have easy access to prescriptions and the use of online pharmacies.
Access to prescriptions through telehealth services has become more frequent since lawmakers relaxed regulations due to the COVID-19 pandemic. This has removed traditional controls, including human monitoring. For investigators, there are no staff or nurses to interview, and no centralized paper trail to confirm that a patient was actually seen and provided with a prescription.
Lastly, prescribers are working in conjunction with pharmaceutical suppliers and being provided kickbacks in order to provide patients with medicines such as Rogaine, Viagra, antidepressants, weight loss medications, and more. Using existing methods, it is difficult to tell whether these organizations are prescribing medication to patients that genuinely need it, or whether they’re acting as pill-mills for expensive treatments.
Fraudsters are Playing Outside of the Rules – So Should Investigators.
One negative side effect of telehealth is that bad actors can hide within the data. In some cases, investigators are confined by traditional business rules. These tend to look at utilization, or they may flag cases where there’s too much distance between the patient and provider. These rules are increasingly irrelevant when it comes to detecting and mitigating telehealth fraud.
AI solutions – unlike rules-based approaches – are able to learn and evolve to stay ahead of these schemes. They help investigators see the more subtle, changing dividers between telehealth providers and fraudulent providers. Additional data sources used by AI are key to increasing visibility and uncovering behaviors outside of the payer’s claim view. This enables features such as identity resolution and sophisticated network analysis which can uncover known bad actors associated with provider networks, and their far reaching relationships. The outcomes and learnings of these investigations are continuously incorporated into the models, increasing detection accuracy of these evolving telehealth fraud schemes.
With guardrails enabled by AI solutions, health payers can safely expand healthcare to a larger member population. Telehealth has the potential to connect quality medical care to those who have had limited access in the past, while providing an overall better quality of care to patients everywhere. With advanced AI solutions to reduce improper payments, telehealth can become a win for both patients and providers alike.
