Going on Offense Against Fraud, Waste and Abuse in Behavioral Telehealth: 3 Key Actions


Telehealth, especially for behavioral health, has created new opportunities for dishonest individuals to file fraudulent claims. Health plans can take steps to stop the fraud before it happens.

A recent Kaiser Health News investigation uncovered breakdowns in federal safeguards to prevent fraud, waste and abuse (FWA) in Medicare and Medicaid claims, noting that systems intended to prevent repeat offenders from exploiting government programs often failed. Many of these difficulties apply equally to private payers, who may not have access to the data necessary to prevent bad actors from submitting inappropriate claims. Amid the challenges of the ongoing COVID-19 pandemic, one significant area of opportunity is minimizing FWA in behavioral telehealth.

Rutzler writes that bad actors tend to focus on vulnerable populations — those who might not spot instances of fraud or abuse as readily.

Rutzler writes that bad actors tend to focus on vulnerable populations — those who might not spot instances of fraud or abuse as readily.

Behavioral health visits are up more than 16% over pre-COVID-19 pandemic levels, and given the shortage of behavioral health providers and the increased need for mental healthcare, the actual demand for behavioral health services is likely higher. Meanwhile, a Cotiviti analysis of data from several health plans shows the volume of behavioral health procedures codes in telehealth visits rose from just 0.5% percent in 2019 to nearly 40% in 2022.

The surge in demand for behavioral health services, combined with the extension of pandemic-era waivers of certain telehealth reimbursement guidelines and increased reliance on virtual care, has created an environment where bad actors can exploit new opportunities for inappropriate reimbursement. Now health plans must determine where weak points exist within behavioral telehealth claim review and reimbursement, and from there create safeguards that protect their members and their organizations.

A new playing field for behavioral health reimbursement

At a time when changes in regulatory oversight have expanded access to telehealth, it is important to be aware of common FWA schemes related to behavioral telehealth claims. These include:

Billing for individual vs. group therapy. This occurs when a provider bills for individual therapy when the patient was treated as part of a virtual group therapy session. In one instance, a Cotiviti claims analysis revealed that 57% of a provider’s encounters included billing for individual psychotherapy visits for multiple members of the same household. A review of medical records uncovered that the 60-minute individual therapy sessions should have been billed as group therapy. The impact of this FWA scheme: more than $500,000 in overpayments to a single provider.

Impossible days. This type of FWA involves discrepancies between hours paid and dates of service. In one analysis, a bad actor coded 96% of tele-behavioral claims as 60-minute psychotherapy visits—significantly higher than tele-behavioral visits recorded by peers. When an analysis reviewed dates of service for unique patients versus the total hours spent per session, there was a significant discrepancy: The provider billed for 26 hours of service and eight patients per date of service on average — and billed more than 24 hours a day on 122 dates of service. Under this “impossible days” scenario, even if it were possible to conduct psychotherapy visits for 24 to 26 hours a day, it is unlikely that multiple patients required sessions lasting several hours a day.

Creative upcoding. Imagine that a provider bills a 60-minute psychotherapy service with an added evaluation and management (E&M) code, which typically denotes an office visit. In this scenario, for the coding to be accurate, the provider would need to provide a “medical service” for the E&M code and a “psychotherapy service” for the PST code. But the likelihood of this combination occurring would be highly unusual. It’s an instance where an FWA expert might investigate the claim to determine why the E&M was warranted, then verify that the provider spent an hour on psychotherapy and kept the patient for an added office visit.

For health plans, uncovering instances of FWA and responding to them presents multiple challenges. Health plans may be reluctant to pursue issues related to behavioral health claims, partly because they view these claims as sensitive and partly because they lack the in-house expertise necessary to dig deeper.

For another, bad actors tend to focus on vulnerable populations — those who might not spot instances of fraud or abuse as readily. These include the elderly, those who suffer from substance use disorder, and individuals who are less likely to review or understand their billing. They also tend to target individuals whose services are fully covered under insurance or who are not paying out of pocket for their care. These members are unlikely to detect instances of overbilling or call attention to higher-than-expected charges.

Building a solid FWA offense

Health plans can avoid having to recover dollars lost to FWA in behavioral telehealth claims by proactively preventing these claims from being paid in the first place. To do so, leaders should consider the following actions to strengthen payment integrity in this area.

  • Change your mindset toward behavioral health claims. Plans may not push back on errors identified with behavioral health claims because they fear coming across as uncaring or insensitive. But behavioral health claims should be viewed similarly to other medical claims — especially when the data look suspicious. Not all instances of billing errors around behavioral telehealth are related to FWA; in fact, some may simply be caused by an inputting error or the need for provider education. Digging deeper not only helps ensure members do not pay more than expected for their care. It protects the health plan’s payment integrity.
  • Tap into outside expertise. By leaning into FWA-specific expertise, particularly around behavioral telehealth, payers can better detect billing activity that reflects the most current schemes that industry experts are seeing. They can also catch data discrepancies that their team might not have been able to catch on their own, whether due to lack of in-house knowledge or capacity. With behavioral health-specific knowledge in house, health plans can more readily catch red flags in telehealth claims, analyze suspicious claims, and detect problematic patterns in claims data. Furthermore, a partner that works with several payers can more readily identify problematic trends within a provider’s submitted claims that may not be identifiable within an individual plan’s own data.
  • Invest in more sophisticated tools for prepay and post-pay integrity and data analysis. With more refined tools and the ability to dive into granular data, health plans can recognize discrepancies in telehealth claims faster. They also gain better insight into which providers may be repeat offenders for FWA. The addition of prepay and postpay integrity solutions also empowers health plans to detect FWA schemes faster. From there, health plans can leverage the learnings from their investigations to optimize prepay claim editing for a more robust approach to fraud and abuse prevention.

By taking a more proactive approach to FWA prevention for behavioral telehealth claims, health plans can better prevent inaccurate claims from being paid and recapture dollars owed. This not only leads to better outcomes for the plan, but protects their members’ plan benefits and helps reduce the likelihood they will be exploited in the future.

Erin Rutzler is vice president of fraud, waste, and abuse for Cotiviti.

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