The seven suspect characteristics are:

The purported patients for whom the practitioner orders or prescribes items or services were identified or recruited by the Telemedicine Company, telemarketing company, sales agent, recruiter, call center, health fair, and/or through internet, television, or social media advertising for free or low out-of-pocket cost items or services.
The practitioner does not have sufficient contact with or information from the purported patient to meaningfully assess the medical necessity of the items or services ordered or prescribed.
The Telemedicine Company compensates the practitioner based on the volume of items or services ordered or prescribed, which may be characterized to the practitioner as compensation based on the number of purported medical records that the practitioner reviewed.
The Telemedicine Company only furnishes items and services to federal health insurance program beneficiaries and does not accept insurance from any other payor.
The Telemedicine Company claims to only furnish items and services to individuals who are not federal health insurance program beneficiaries but may in fact bill federal health care programs.
The Telemedicine Company only furnishes one product or a single class of products (e.g., DME, genetic testing, diabetic supplies, or various prescription creams), potentially restricting a practitioner's treating options to a predetermined course of treatment.
The Telemedicine Company does not expect practitioners to follow up with purported patients nor does it provide practitioners with the information required to follow up with purported patients (e.g., the Telemedicine Company does not require practitioners to discuss genetic testing results with each purported patient).

Conclusion

The OIG noted in its Alert that it was not intending to discourage legitimate telehealth arrangements, and it seems clear that telemedicine is quickly growing in acceptance throughout the health care system. This growing acceptance, however, is not lost on the many crooked individuals who are constantly looking for new ways to illegally exploit insurance benefits for their own personal profit. Hopefully, with the increased government scrutiny facing telemedicine, the inevitable fraud and abuse can be contained and the benefits of telemedicine fully realized.

Instant Insights /

As telemedicine expands, insurance fraud grows

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