On July 20, 2022, the HHS Inspector General’s Office (OIG) will issue a special Fraud Warning to doctors and other healthcare professionals when entering into a telemedicine contract that has “suspicious characteristics” of a fraud scheme. warned of “increased scrutiny.” The release of Alert follows significant enforcement actions by federal regulators as patients and practitioners become accustomed to providing care via telemedicine.
Special Fraud Alert Release Announced Coinciding with Criminal Indictment in $1.2 Billion Telemedicine Fraud Scheme
As we recently reported in our investigative blog, on July 20, 2022, the U.S. Department of Justice (DOJ) will open allegations of fraud totaling over $1.2 billion, including telemedicine, cardiovascular and cancer genetic disorders. filed criminal charges against dozens of defendants across the country. testing, and durable medical equipment (DME) schemes. The indictments focused primarily on the owners and operators of the lab, which they allege DOJ paid illegal kickbacks and bribes in exchange for patient referrals by medical professionals working with rogue telemedicine and digital medical technology companies. I guess.
On the same day as the DOJ’s announcement, the OIG will sell telemedicine, telemedicine, or telemarketing services such as those DOJ claims in its criminal complaint (collectively referred to in the alert as telemedicine companies).
What does a fraudulent telemedicine arrangement look like?
According to the OIG, fraudulent telemedicine arrangements “are differently designed and operated, involving a variety of individuals and entities, including international and domestic telemarketing call centers, staffing agencies, medical practitioners, marketers and brokers. ”
But these arrangements often have one important thing in common. It is the payment of rebates to individuals who have little, if any, interaction with a practitioner when a doctor or other practitioner orders or prescribes medically unnecessary items or services. Telemedicine companies often solicit and recruit so-called “patients” to sell a practitioner’s prescriptions or orders to another party. That third party then fraudulently bills federal health programs and/or other payers for items and services.
Examples of these “questionable” arrangements include, starting in August 2021, the DOJ filing criminal charges against the owners of multiple telemedicine companies for orchestrating $784 million in false and fraudulent claims against Medicare. Arrangements for the provision of DME are included, as if done. In that case, DOJ alleged that the telemedicine company facilitated the practitioner’s order for medically unnecessary prosthetic appliances and medications that the DME supplier billed to her Medicare. DME suppliers then used the revenue received to pay rebates to telemedicine companies and order takers through various intermediary entities. According to the DOJ, it was “one of the largest Medicare fraud schemes the Department of Justice has ever prosecuted.” (You can read more about this case in our investigative blog here.)
‘Doubtful Features’ of Fraudulent Telemedicine Arrangements
In the alert, the OIG highlighted seven “suspicious features” related to practitioner arrangements with telemedicine companies.
- Eligible patients for whom a practitioner orders or prescribes an item or service may contact telemedicine companies, telemarketers, distributors, recruiters, call centers, health fairs, and/or through free advertising on the Internet, television, or social media. identified or solicited. or low out-of-pocket items or services.
- Practitioners do not have sufficient contact with, or obtain information from, the purported patient to meaningfully assess the medical need for the item or service ordered or prescribed.
- Telemedicine companies compensate practitioners based on the volume of items or services ordered or prescribed. This may be characterized to the practitioner as compensation based on the number of medical records the practitioner is alleged to have reviewed.
- The Telemedicine Company provides items and services only to federal health program beneficiaries and does not accept insurance from other payers.
- The Telemedicine Company claims to provide items and services only to individuals who are not federal health program beneficiaries, but who may in fact bill for the federal health care program.
- A Telemedicine Company may offer only one product or class of products (e.g., DME, genetic testing, diabetic products, or various prescription creams), which may limit a practitioner’s treatment options to a prescribed course of treatment. There is a nature.
- The Telemedicine Company does not expect an ordering practitioner (or another practitioner) to follow up a patient referred to as a patient, nor does the Telemedicine Company expect the ordering practitioner to follow up a patient referred to as a patient. Nor do we expect them to provide the necessary information (for example, the Telemedicine Company does not require practitioners to discuss their patients). results of the genetic tests they ordered for each patient referred to).
If one or more of these factors are present in an arrangement with a telemedicine company, the parties to the arrangement may face liability under the Anti-Kickback Act (AKS) and other fraud and abuse laws. AKS prohibits the willful and intentional exchange of anything of value for the referral of items or services that are reimbursed by Medicare, Medicaid, and other federal health care programs. Participation in rebate trading can result in felony criminal prosecution by the DOJ and penalties by the OIG, including civil financial penalties and exclusion from federal health care programs. Kickback arrangements may also be grounds for DOJ or private whistleblowers to file civil lawsuits under the Federal False Claims Act. Under this law, claims to the Federal Health Care Program for items or services related to kickback schemes are considered “false” or “false.” scam. ”
The OIG’s special fraud alerts are relatively rare, so their release is usually a strong indicator that the OIG considers them an enforcement priority. With this latest alert, the OIG’s main clear goal is to inform physicians and other healthcare professionals of the red flags to watch out for as telemedicine arrangements become increasingly common. At the same time, however, the OIG cautions practitioners that to the extent they participate in fraudulent arrangements with telemedicine companies, they may be personally liable for violations of AKS and other fraud and abuse laws. I’m here. As the OIG, DOJ, and other federal agencies continue to take aggressive enforcement actions to combat fraudulent telemedicine schemes, practitioners should heed the OIG’s warnings and pay particular attention to the suspicious features outlined by the OIG. While paying, telemedicine arrangements should be carefully considered.