Rollbacksin telehealth regulations could prove controversial and affectpatient safety — from relaxing restrictions on opioid prescriptionsvia video to easing licensing requirements. (Photo:Shutterstock)

On March 17, Medicare chief Seema Verma stepped to the podium ata White House coronavirus briefing and unveiled a "historic action" to promote virtualmedical care, or telehealth.

Verma temporarily lifted a variety of federal restrictions onthe use of the service, which had been limited to rural areas. Shepraised telehealth, saying it could handle routine care for anolder patient with diabetes without risking a visit to a medicaloffice. She said a Medicare recipient with mild flu-like symptomscould receive advice from a doctor at home "instead of leaving thehouse and sitting in a waiting room full of other vulnerablepeople."

Related: Coronavirus tests telemedicineindustry

But the Trump administration's action also raised concerns thatit could inadvertently unleash a wave of billing fraud and abuseand risk patient safety — especially if officials yield to industrypressure to make many of the emergency policy changespermanent.

"There are unscrupulous providers out there, and they have muchgreater reach with telehealth," said Mike Cohen, an operationsofficer with the Health and Human Services Inspector General'sOffice, which investigates health care fraud. "Just a few can do awhole lot of damage."

Telehealth — or telemedicine, as it's also known — covers abroad range of services via video, telephone or email. In earlyMarch, the Centers for Medicare & Medicaid Services approveddozens of new billing codes to allow medical professionals to billfor these services. That means patients can consult with doctorsabout everything from flu symptoms or a backache to a psychiatryvisit.

Federal officials also allowed telemedicine providers to waivepatient deductibles and copayments during the coronavirusemergency. Under normal conditions, these actions can be construedas a kickback because they discourage patients from complainingabout charges or can lead to overuse of medical services. Suchtactics normally can lead to civil or criminal penalties.

Cohen said anti-fraud "guardrails have been removed under thisepidemic. The concern is that things will never go back to whatthey were. … There will be a lot of pressure on CMS to make atleast some of these changes permanent."

Officials worry that some telemedicine companies may takeadvantage of Medicare patients they contact at their homes. Some ofthe largest recent Medicare fraud cases have implicated this sortof marketing, often for bogus genetic testing, or prescribingunnecessary pain creams or delivering unwanted medical equipment.In some cases, the companies have employed telemarketers to callthousands of people on Medicare and offer them a free service inorder to obtain their patient ID numbers, which can be used to billthe government.

These fraudulent activities can become massive because phonerooms operating anywhere in the world can target thousands ofpatients and Medicare may have difficulty differentiating improperbills from those submitted by a legitimate telehealthoperation.

In September 2019, the Justice Department charged 35 people inconnection with a telemedicine scheme that allegedly ripped offmore than $2.1 billion from Medicare, among the largest such frauds in U.S. history.

Cohen said investigators already are seeing "tons" of fraud cases linked directly to COVID-19, including usingpatient accounts to bill for "coronavirus emergency kits" thatcontain nothing but gloves and hand sanitizer or bogus testingkits. Once marketers obtain a patient's billing numbers, they oftentack on thousands of dollars in genetic tests that are of no valueto the medical case, investigators said.

Other rollbacks in telehealth regulations could provecontroversial and affect patient safety — from relaxingrestrictions on opioid prescriptions via video to easing licensingrequirements for doctors who practice across state lines.

In a statement to Kaiser Health News, CMS said it is"instructing its payment and audit contractors to review claimsduring this public health emergency based on all agency waivers andflexibilities that have been put into place. This includes claimsfor services furnished under the telehealth flexibilities." CMSalso said it would put "a strong emphasis" on program integrity andcost in considering whether to make any telehealth changespermanent.

The telemedicine industry argues that its operations are no moreprone to billing abuses than any other branch of health care.

"A crisis always spawns fraudsters," said Krista Drobac,executive director of the Alliance for Connected Care, whichadvocates for telehealth.

She said the alliance hopes "to show the value of telehealth"and help win wide acceptance of virtual visits to doctors. Thegroup wants to see some of the regulatory changes made permanent inorder to assure the industry's viability once things return tonormal.

Telehealth advocates also argue they have successfully steppedin to fill a void caused by many doctors temporarily shutting downtheir offices.

The coronavirus has "stopped [the medical] profession in itstracks, and we need to adapt to a new reality," said Dr. JosephKvedar, a Harvard Medical School professor and president-elect ofthe American Telemedicine Association, a nonprofit that promotesaccess to the technology.

Kvedar said virtual visits at Partners HealthCare, where he is asenior adviser, have jumped from 1,600 virtual visits in February2019 to 90,000 in March.

He said other health networks have reported similar spikes, inone case in New York City ramping up from zero to 5,500 visits in asingle day. "There's a lot more interest now that people have tostay home."

Congress did much to speed acceptance of telehealth as part ofthe $2 trillion stimulus package. The CARES Act awards $200 millionthrough the Federal Communications Commission to medical groups tohelp them install the technology and fund broadband installations.The groups also can apply for $27 billion in a public healthemergency fund.

In the March 17 briefing, Verma added that CMS wanted to givemedical professionals relief from regulations that could take timeaway from treating patients.

"In an emergency, those on the front lines shouldn't have toworry about federal rules and red tape hamstringing them when theyneed flexibility above all else. And we're doing everything in ourpower to make sure that that doesn't happen," Verma said.

CMS also is allowing Medicare Advantage plans, which togethertreat more than 22 million Americans, to use telehealth to help setpayment rates. On March 30, CMS said it would suspend some efforts to recover hundreds of millions of dollarsin overpayments made to the health plans.

Lindsey Copeland, federal policy director for the MedicareRights Center, said her group agreed that telehealth could helpensure that people on Medicare would "not be forced to putthemselves in harm's way to obtain needed care."

Copeland said making some of the telehealth changes permanentmight make sense. But she said, "We urge caution in rushing suchpolicymaking."

By contrast, the industry sees itself as on a roll. InSight +Regroup, a national telepsychiatry company, noted that it "feelsstrongly about advocating to keep the telehealth-friendlyregulations that were rapidly put into place in response toCOVID-19."

"Telehealth is going mainstream," said company CEO GeoffreyBoyce. "It has been on the fringes for a number of years. We're atthe point now where there is no going back."

His company also wants to reverse Medicare's prohibition ondoctors living outside the U.S. treating patients here usingtelehealth. Boyce said the company would use only doctors whotrained and are certified in this country.

There's little doubt that the coronavirus crisis has broughttelehealth to the forefront of medicine, something that years oflobbying in Washington couldn't accomplish.

The Alliance for Connected Care, a group that advocatestelehealth and whose more than three dozen members range fromAmazon to the Michael J. Fox Foundation for Parkinson's Research,spent more than $1 million on lobbying from 2016 to 2019, accordingto the Center for Responsive Politics.

But now "the numbers of [virtual] visits are astounding," saidDrobac, the alliance's executive director.

KaiserHealth News is a nonprofit news service coveringhealth issues. It is an editorially independent program of theKaiser Family Foundation, which is not affiliated with KaiserPermanente.

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