Telehealth Fraud Investigations: What the Claims Leave Out

Telehealth fraud investigations connect a billed service or signed order to the care provided, the money paid and the people who controlled the transaction. Claims data can identify unusual billing. An insider can explain who supplied the patient information, what the clinician actually reviewed and why the order went through. A completed form may tell a very different story from the person whose name appears on it. When Medicare pays for care that never happened, taxpayers pay the bill.

An investigation can grow from a billing review, a referral or a whistleblower’s account. In Health Wealth Safe, the Justice Department said a lawsuit by former employees started the investigation. Their knowledge concerned the monitoring business behind the Medicare claims. That is the value of an insider: the ability to explain the transaction the government can see only in pieces.

Who Is Responsible for Combating Healthcare Fraud and Abuse?

The Justice Department, the Department of Health and Human Services’ Office of Inspector General, the Federal Bureau of Investigation and state Medicaid Fraud Control Units investigate and pursue healthcare fraud. The Centers for Medicare & Medicaid Services and its contractors also examine billing and refer matters for enforcement.

What Federal Agency Investigates Fraud?

The Inspector General investigates fraud involving federal health programs, while the FBI investigates federal and private health-insurance fraud. The Justice Department and U.S. Attorneys pursue civil False Claims Act cases and criminal prosecutions. The inspector general’s office also conducts audits and evaluations that can identify billing patterns for further review.

In the Centers for Medicare & Medicaid Services’ program-integrity work, Medicare Administrative Contractors process and review claims. Unified Program Integrity Contractors investigate suspected fraud, develop overpayment findings and refer matters to law enforcement.

At the state level, Medicaid Fraud Control Units investigate and prosecute Medicaid provider fraud. They operate separately from the Medicaid agencies that oversee payment. Medical boards address professional discipline, while state prosecutors can pursue their own civil or criminal cases.

The Order Can Be the Product

A telehealth investigation may follow the money beyond the remote encounter to a laboratory, pharmacy or durable medical equipment supplier. The practitioner supplies the order. Another business submits the claim and receives the program’s payment. The remote consultation itself may never be billed. A staffing company’s role in procuring orders that produce false claims can bring it into a False Claims Act case, even when it never bills Medicare itself.

The industry is built from businesses with different jobs. A platform may supply the portal, a professional practice the clinician, and a management company the scheduling and billing staff. A monitoring vendor may supply the device and data connection. The brand the patient recognizes can be several steps removed from the business that bills.

In the order arrangements described in the Inspector General’s telemedicine fraud alert, marketers, call centers, staffing businesses and practitioners helped produce orders for downstream billers. Recruited beneficiaries, limited clinical contact, payments tied to orders and a predetermined product make the operational questions concrete. Who chose the product? What information reached the practitioner? What did the payment reward? Those questions lead to the contract, the original intake, the signed order and the supplier’s claim.

Seven Claims Screens OIG Used to Select Providers

The Inspector General’s September 2022 telehealth report identified 1,714 providers with high-risk billing among approximately 742,000 who billed for telehealth services. It examined individual practitioners’ Medicare fee-for-service claims and Medicare Advantage encounters approved for payment from March 1, 2020, through February 28, 2021.

The seven screens looked for these billing patterns:

1. Both professional and facility fees. Billing a telehealth service and an originating-site facility fee for more than 75% of visits.
2. The highest service level every time. Always billing the most expensive level within a specified category, such as office or nursing-home visits.
3. An unusually long working year. Billing telehealth services on more than 300 days.
4. The same service billed to both programs. Billing Medicare fee-for-service and a Medicare Advantage plan for the same beneficiary, service and date for more than 20% of services.
5. High modeled hours per visit. Billing services representing an average of more than two hours per visit.
6. An unusually large patient count. Billing telehealth services for at least 2,000 beneficiaries.
7. Equipment following the visit. Ordering medical equipment and supplies for at least half of the provider’s telehealth beneficiaries, with the equipment billed within three months of the service.

Concerning billing could also fall below the report’s thresholds. The Inspector General said it would refer the identified providers to the Centers for Medicare & Medicaid Services, which agreed to follow up.

Modeled Hours and Missing Names

The report calculated visit hours from the Centers for Medicare & Medicaid Services’ median minutes for the billed services. Those hours describe what the codes represented. To establish the actual work, investigators need the encounter record, clinical contact and staff activity behind those codes.

The report also described a visibility problem. Services delivered by supervised clinical staff could appear under the supervising practitioner’s identification number. The Inspector General could not identify that billing reliably enough to use a measure of providers billing more than 24 hours in a day.

Company identity was another gap. The Inspector General looked at billing-provider names for apparent connections to telehealth companies, but reported that Medicare data had no systematic way to identify those companies. An employee who knows which business controlled scheduling, forms and compensation can supply a connection missing from the claim.

What Evidence Is Needed to Prove Fraud?

Telehealth fraud evidence connects a claim or signed order to what actually happened. People who understand those records explain the decisions behind them.

A platform worker may understand what a timestamp measures: opening a file, reviewing a packet, signing an order or completing an encounter. That distinction matters when a dashboard appears to show impossible speed. We connect those records with the people who understand how the system produced them.

What the Cases Show Behind the Billing

Aptihealth’s No-Shows and Patient Messages

Aptihealth‘s billing admissions put two different questions before an investigator: whether a Medicare or Medicaid appointment occurred, and whether a billed patient-message response contained billable clinical content. The comparison connects the billed service to the care actually provided, rather than relying on the completed form alone.

A Staffing Fee That Depended on Approval

Jackson & Coker LocumTenens admitted an approval-based staffing fee arrangement. That contract connected the staffing business to the orders behind Medicare claims.

A Brace for an Amputated Leg

In a separate civil settlement involving a physician who worked through RediDoc, the Justice Department described a doctor reviewing recorded telemarketing calls and prefilled prescriptions, with payment for each signed order. The government said he expressed doubts about the work in an email and continued signing.

The government’s account included an order for braces for both knees of a woman whose right leg had been amputated above the knee. The patient’s actual condition, the order and the earlier email made the inquiry specific.

A Portal Approval Became a Signed Certification

In the admitted facts of a physician’s civil settlement, a MySpecialistMD portal approval applied her signature to medical documents. For an investigator, the question is what the physician reviewed against what those documents certified.

Monitoring and Prescribing Leave Different Records

Remote patient monitoring separates device setup, data transmission and clinical management. A transmission day and a minute of management measure different work. The investigation follows the particular billed component and the requirements in force when the service occurred.

Health Wealth Safe’s civil settlement concerned allegations that devices lacked the connectivity needed to report readings automatically. That places device capability and transmission records at the center of the payment question. Management-time billing calls for separate evidence of clinical work and communication.

Who Investigates Prescription Fraud?

The Drug Enforcement Administration investigates controlled-substance conduct and handles registration proceedings. The FBI, the inspector general’s office and the Justice Department may investigate prescription-related health care fraud, depending on the payer and conduct.

Inside a prescribing platform, the relevant records can include compensation terms, refill rules, clinical refusals, patient reassignment and warnings. Those records show how the business influenced prescribing decisions. We examine the prescription, the operating instructions and the payment claim together.

The Whistleblower Case Follows the Recovery

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The payer, the false claim and the insider’s knowledge shape the case we build with you.

You Know How the Orders Got Through

If you work in clinical care, billing, staffing or platform operations and can explain the gap between the paperwork and the work, speak with our whistleblower experts about that gap. We build your strongest telehealth whistleblower case around the claims, the money and the decisions that kept the business running. We stay beside you throughout the case and bring in telehealth fraud whistleblower lawyers who understand these arrangements.