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Characteristics of Telehealth Fraud According to the OIC and DOJ

On Behalf of | Dec 21, 2023 | Health Care Fraud

The intersection of telemedicine and legal compliance has become increasingly complex. To start, the Office of Inspector General and the Department of Justice have felt compelled to highlight certain characteristics of practitioner arrangements with telemedicine companies that pose heightened fraud and abuse risks, given the shifting nature of the industry.

While this guidance isn’t exhaustive, and these factors alone don’t determine legal culpability, they serve as critical markers for legal scrutiny.

Patient recruitment methods

A significant red flag arises when patients are recruited through telemarketing, sales agents, internet, television or social media advertising, especially when promising free or low-cost services. Such practices suggest a model more focused on volume than genuine patient care.

Inadequate practitioner-patient interaction

Another concern is the lack of sufficient contact or information for the practitioner to assess the medical necessity of the services ordered. A reliance on audio-only technology or insufficient medical records indicates a superficial engagement that undermines the essence of telehealth.

Compensation based on volume

A compensation model that incentivizes practitioners based on the volume of items or services ordered rather than the quality of care also raises questions. This approach can lead to unnecessary treatments that directly contradict the principles of medical necessity and patient care.

Limited payor acceptance

The exclusive servicing of federal health care program beneficiaries or of only servicing only non-federal program beneficiaries can indicate problematic billing practices. This selectivity in patient demographics can be a facade for fraudulent activities.

Restrictive treatment options

A telemedicine company that limits practitioners to prescribing only certain products or a single class of products can be problematic. Such restrictions might lead to a one-size-fits-all approach to treatment, which is rarely in the best interest of patients.

Lack of follow-up care

An absence of expectations for practitioners to follow up with patients or not providing necessary information for follow-up is a crucial indicator of concern. For instance, not requiring practitioners to discuss test results with patients indicates a lack of commitment to comprehensive patient care.

While the presence of those characteristics doesn’t automatically mean a telemedicine provider is breaking the law, it’s a good indicator that caution is necessary. Anyone who learns they’re under investigation or facing charges for telehealth fraud should learn about their defense options immediately, as this kind of alleged wrongdoing is being prosecuted aggressively.