Unnecessary Repeat Telehealth Visits: When Revenue Targets Set the Schedule

Unnecessary telehealth visits billing fraud involves charging for repeat remote appointments scheduled to generate revenue rather than meet patient needs. The patient may attend, and the clinician may complete the visit. The decision worth examining happened earlier, when someone chose how soon that patient had to return. If you work in scheduling, practice management or billing, you may know who chose the interval and what staff were told.

Physician Partners of America Allegedly Replaced Lost Revenue With Repeat Visits

Physician Partners of America allegedly shortened the interval between telehealth appointments to replace revenue lost when Florida suspended non-emergency medical procedures in March 2020. According to the Justice Department’s settlement announcement, the company required physician employees to schedule unnecessary evaluation and management appointments every 14 days, replacing its prior monthly practice. It also allegedly instructed physicians to use inappropriate high-level procedure codes.

The allegation puts the business decision before the clinical decision. In the government’s account, patients became the means of replacing the missing income. Patients faced unnecessary appointments, and taxpayer-funded healthcare programs received the bills.

The telemedicine allegation combines frequency and coding. Requiring a patient to return too often creates additional visits to bill. Assigning an inappropriate high-level code inflates the charge for each visit. A billing department sees the codes. A scheduler may know why patients started coming back sooner.

The Justice Department announced a $24.5 million civil settlement on April 12, 2022. The settlement also covered allegations involving unnecessary testing, physician compensation tied to testing and a false statement in a pandemic relief loan application. The recurring-visit allegation was part of that broader resolution.

Who Set the Repeat-Visit Schedule?

Scheduling instructions and management agreements identify who controlled the return interval. The question is whether the schedule followed the patient’s treatment plan or management’s revenue target.

Control can sit outside the treating professional’s immediate team. A management company may supply scheduling and billing staff while a professional practice supplies the clinician. That matters when a clinician’s name appears on the claim but someone else set the appointment policy.

Whether clinicians could lengthen the interval based on patient need is a concrete question. Instructions about exceptions show how much room the practice gave the treating professional to make that decision. We examine who issued the instruction, the discretion clinicians had and the billing that followed.

A Completed Visit Leaves More Than an Attendance Record

A completed telehealth visit still has to support the service billed and the reason for another appointment. For repeat visits, the question is what clinical need the additional encounter addressed, and how that need fits the standing return instruction.

The same question about clinical content arises in message billing. Aptihealth admitted in its civil settlement agreement to billing messages without sufficient regard to their clinical content.

What Is a Red Flag for Health Care Fraud?

A repeat-visit instruction tied to replacing lost income is a red flag for health care fraud. In Physician Partners’ case, the alleged direction to use high-level codes added another connection between the practice’s revenue problem and the claims.

The HHS Office of Inspector General’s September 2022 telehealth review flagged 1,714 providers among approximately 742,000. Its screens included providers billing every service in a specified category at the highest level, unusually many service days and large patient counts. The report called for further investigation into the flagged providers.

An insider can supply the explanation behind a pattern: the instruction that changed the schedule, the reason given for that change, and the direction about coding. Claims show the pattern across patients. The person who received the instruction knows what management asked staff to do.

How Another Visit Becomes More Revenue

Payment by the visit gives the appointment schedule financial weight. Teladoc’s annual filing describes access-only, visit-only and combined arrangements. The actual contract tells us what another appointment earns and which business receives that money.

A 2015 economic commentary, FSMB Interstate Medical Licensure Compact: An Economist’s View, in the Journal of American Physicians and Surgeons, describes how limits on the price of a service can shift the response into the number of services:

The commentary illustrates the point with a procedure spread over two visits after previously taking one. Physician Partners allegedly faced a different financial pressure, lost procedure income, and responded through more appointments. The economic question is recognizable to a finance employee: which revenue was the practice trying to replace, and which service generated the replacement claim?

What Evidence Is Needed to Prove Fraud?

Evidence of unnecessary repeat telehealth visits connects the scheduling decision, patient need, encounter, coding instruction and payer claim. The strongest account explains both what the business billed and who directed the conduct behind the billing.

A clinician’s objection to a standing return rule may be especially revealing. If management renewed the instruction after the clinician questioned the need for repeat visits, that exchange would show how management responded to a clinical concern. We work through those decisions with the person who knows the operation.

For a False Claims Act case involving Medicare billing, we connect the alleged unnecessary visits to the government-funded claims and the decisions that caused them. Knowing the internal scheduling rule gives us a place to start.

Can You Get Money for Reporting Fraud?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The Physician Partners settlement included qui tam claims brought by current or former employees.

When You Know Why Patients Had to Return

If the instruction to fill the schedule came from a revenue target, talk to our whistleblower experts about who set that target and how the visits were billed. We work beside you to build the case around the decisions you know, connect them to the claims, and bring in telehealth billing whistleblower lawyers who understand medical-necessity cases. We stay with you through the whole journey.