U.S. Department of Health and Human Services  
 Office of Inspector General 
 
Data Brief 
 
 September 2022, OEI-02-20-00720 
 
Medicare Telehealth Services During the First Year of the Pandemic: 
Program Integrity Risks  
Why OIG Did This Review  
Key Takeaways 
The COVID-19 pandemic created unprecedented challenges for 
how Medicare beneficiaries access health care.  In response, the 
o  Our findings demonstrate the 
Department of Health and Human Services (HHS) and the Centers 
importance of effective, 
targeted oversight of  for Medicare & Medicaid Services (CMS) took a number of 
telehealth services to ensure  actions to temporarily expand access to telehealth for Medicare 
that the benefits of telehealth  beneficiaries.1  In addition, CMS temporarily paused several 
are realized while minimizing  program integrity activities, including medical reviews of claims.2  
risk. 
In a related report, the Office of Inspector General (OIG) found 
o  We identified 1,714 providers 
that the use of telehealth increased dramatically during the first 
out of approximately 742,000 
year of the pandemic.3  More than 28 million Medicare 
whose billing for telehealth 
beneficiariesabout 2 in 5used telehealth services that first 
services poses a high risk to 
Medicare.  year.  In total, beneficiaries used 88 times more telehealth 
services during the first year of the pandemic than they did in the 
o  Each of these providers had 
prior year.   
concerning billing on at least 
one of seven measures that 
The changes to Medicare telehealth policies, along with the 
may indicate fraud, waste, or 
dramatic increase in the use of telehealth, underscore the 
abuse.   
importance of determining whether providers are billing for 
o  These providers billed for  telehealth services appropriately and how to best protect 
telehealth services for about 
Medicare and beneficiaries against fraud, waste, and abuse.   
half a million beneficiaries. 
This data brief describes providers billing for telehealth services 
o  Many of these providers are a 
and identifies ways to safeguard Medicare from fraud, waste, and 
part of the same medical 
practice as at least one other  abuse related to telehealth.  This information can help CMS, 
provider whose billing poses a  Congress, and other stakeholders determine what safeguards 
high risk.  may be needed as they consider permanent changes to 
telehealth policies in Medicare.   
This report is part of a series that examines the use of telehealth in Medicare and the characteristics of 
beneficiaries who used telehealth during the pandemic.4  
How OIG Did This Review 
This data brief is based on an analysis of Medicare fee-for-service claims data and Medicare Advantage 
encounter data for the first year of the pandemic from March 1, 2020, to February 28, 2021.  We 
focused our analysis on the approximately 742,000 providers who billed for a telehealth service.  Using 
input from OIG investigators, we developed seven measures that focus on different types of billing for 
telehealth services that may indicate fraud, waste, or abuse.  For each of these measures, we set very 
     
high thresholds to identify providers whose billing poses a high risk to Medicare.  Because this data 
brief focuses on specific measures with very high thresholds, it does not capture all concerning billing 
related to telehealth services that may be occurring in Medicare.  Additionally, this report does not 
confirm that any particular provider is engaging in fraudulent or abusive practices.  Any determination 
of fraud or an overpayment would require additional investigation.  
Further, a Medicare billing practiceknown as incident to billingcreates challenges for oversight 
because it allows services provided by clinical staff who are directly supervised by a practitioner to be 
billed under the supervising practitioners identification number.  It is critical for program integrity 
efforts to identify the individual who delivered the telehealth service that is billed to Medicare.  To 
address these limitations in the data, we developed measures for this report that aim to minimize the 
effect of incident to billing on the results of the claims analysis.   
What OIG Found 
We identified 1,714 providers whose billing for telehealth services during the first year of the pandemic 
poses a high risk to Medicare.  These providers billed for telehealth services for about half a million 
beneficiaries.  They received a total of $127.7 million in Medicare fee-for-service payments.   
Each of these 1,714 providers had concerning billing on at least 1 of 7 measures we developed that may 
indicate fraud, waste, or abuse of telehealth services.  All of these providers warrant further scrutiny.  For 
example, they may be billing for telehealth services that are not medically necessary or were never 
provided.   
In addition, more than half of the high-risk providers we identified are a part of a medical practice with 
at least one other provider whose billing poses a high risk to Medicare.  This may indicate that certain 
practices are encouraging such billing among their associated providers.  Further, 41 providers whose 
billing poses a high risk appear to be associated with telehealth companies; however, there is currently 
no systematic way to identify these companies in the Medicare data.   
What OIG Recommends 
Although these high-risk providers represent a small proportion of all providers who billed for a 
telehealth service, these findings demonstrate the importance of strong, targeted oversight of 
telehealth services.  The findings also offer insight on how Medicare and others can protect 
beneficiaries against fraud, waste, and abuse.  Conducting targeted oversight of telehealth will help 
ensure the benefits of telehealth are realized while minimizing risk in an effective and efficient manner.  
Accordingly, we recommend that CMS: (1) strengthen monitoring and targeted oversight of telehealth 
services, (2) provide additional education to providers on appropriate billing for telehealth services, (3) 
improve the transparency of incident to services when clinical staff primarily delivered the telehealth 
service, (4) identify telehealth companies that bill Medicare, and (5) follow up on the providers identified 
in this report.  CMS concurred with our recommendation to follow up on the providers identified in this 
report, but CMS did not explicitly indicate whether it concurred with the other four recommendations.   
 
 
 
     
 
Primer on:      Medicare Telehealth Services During the Pandemic 
 
  Medicare telehealth services refer to services that are provided remotely 
 
using technology between a provider and a beneficiary.5   
 
 
  The services that can be provided via telehealth include office visits, 
 
behavioral health services, nursing home visits, and home visits, among 
 
others.  Most of these services can also be provided in person.  (See Appendix 
 
A for a description of these services.)  
 
    A group of services known as virtual care services is always provided 
  remotely.6  An example of these services is a telephone call with a provider to 
  discuss a beneficiarys medical condition.  
 
  During the pandemic, CMS allowed beneficiaries to use telehealth to access a 
 
wide range of services in different locations, including in urban areas and 
 
from the beneficiarys home.  Prior to the pandemic, beneficiaries were 
 
allowed to use telehealth only from medical facilities located in rural areas, with 
 
a few exceptions.7  
 
  During the pandemic, CMS increased the types of services that beneficiaries   
  could use via telehealth, from 118 to 264 services.8  Medicare pays providers 
 
the same rate for services provided via telehealth and in person.  
 
    During the pandemic, CMS expanded the use of audio-only for certain types 
  of telehealth services, such as office visits and behavioral health services.  Prior 
  to the pandemic, only audio-video was allowed for the delivery of telehealth 
  services, with a few exceptions.9 
 
56789
 
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Primer | 3     
 
RESULTS 
 
 
This data brief describes providers billing for telehealth services during the first year 
of the pandemic and identifies ways to safeguard Medicare from fraud, waste, and 
abuse related to telehealth.  Each of the providers identified in this report had 
concerning billing on at least one of seven measures we developed that may indicate 
fraud, waste, or abuse.  (See Exhibit 1.)  For each measure, we set very high thresholds 
to identify providers who had concerning billing.  Because this data brief focuses on 
specific measures with very high thresholds, it does not capture all concerning billing 
related to telehealth services that may be occurring in Medicare.   
The seven measures that we developed focus on different types of billing for 
telehealth services that may indicate fraud, waste, or abuse.  Some of these billing 
practices also occur with in-person services, such as always billing for the most 
expensive codes.  These measures do not include telemarketing fraud that does not 
involve billing for telehealth services.  Telemarketing fraudoften referred to as 
telefraudgenerally involves a phone call or other remote interaction with a 
beneficiary to order or prescribe medically unnecessary testing, equipment, or 
prescriptions.10  This data brief is based on Medicare fee-for-service claims data and 
Medicare Advantage encounter data for the first year of the pandemicfrom March 
1, 2020, to February 28, 2021.11   
Exhibit 1: Program Integrity Measures 
To identify providers whose billing for telehealth services poses a high risk to Medicare, we 
developed seven measures based on analyses of the Medicare data and input from OIG 
investigators.  These measures focus on different types of billing that providers may use to 
inappropriately bill for telehealth services and include: 
  billing both a telehealth service and a facility fee for most visits; 
  billing telehealth services at the highest, most expensive level every time; 
  billing telehealth services for a high number of days in a year; 
  billing both Medicare fee-for-service and a Medicare Advantage plan for the same 
service for a high proportion of services; 
  billing a high average number of hours of telehealth services per visit; 
  billing telehealth services for a high number of beneficiaries; and 
  billing for a telehealth service and ordering medical equipment for a high proportion of 
beneficiaries. 
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More than 1,700 providers billed for telehealth services in a 
manner that poses a high risk to Medicare 
In total, we identified 1,714 providers whose billing for telehealth services during the 
first year of the pandemic posed a high risk to Medicare.  Each of these providers had 
concerning billing on at least one of seven measures we developed that may indicate 
fraud, waste, or abuse of telehealth services.  Although these providers represent a 
small proportion of the approximately 742,000 providers who billed for a telehealth 
service, their billing raises concern. 
These seven measures focus on different types of billing that providers may use to 
inappropriately maximize their Medicare payments.  For each of these measures, we 
set very high thresholds to identify providers who had concerning billing.  There could 
be additional providers with concerning billing that fell below our thresholds.  
Additionally, this report does not confirm that a particular provider is engaging in 
fraudulent or abusive practices.  Any determination of fraud or an overpayment would 
require additional investigation. 
The vast majority (1,696) of the providers we identified had concerning billing on 1 of 
the 7 measures, while 18 providers had concerning billing on 2 measures.  Each of 
these 1,714 providers warrant further scrutiny.  They may be billing for telehealth 
services that are not medically necessary or were never provided.  Their billing also 
raises concerns about the quality of services being provided.12  
In total, these 1,714 providers billed 
for telehealth services for about half a 
Providers Whose Billing Poses a 
million beneficiaries.  They received a 
High Risk to Medicare 
total of $127.7 million in Medicare 
fee-for-service payments.13  This  o  Billed telehealth services for 
amountand all dollar amounts in  about half a million 
this reportare those paid by  beneficiaries. 
Medicare fee-for-service only; the 
o  Received a total of $127.7 
amounts paid by Medicare 
million in Medicare fee-for-
Advantage plans to providers are not 
service payments. 
reported to Medicare.   
   
In addition, multiple providers with 
concerning billing are a part of the same medical  practice.  In total, 991 of the 1,714 
providers are a part of the same medical practice as at least one other provider whose 
billing poses a high risk.14  This may indicate that certain practices  encourage such 
billing among their associated providers.  
Further, 41 providers who had concerning billing appear to be associated with 
telehealth companiescompanies that employ practitioners to provide on-demand 
telehealth services to beneficiaries.15  Unlike other providers, telehealth companies do 
not offer in-person services.  We identified providers who appear to be associated 
with a telehealth company by reviewing the name of the provider billing Medicare; 
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OEI-02-20-00720  Results | 5     
there is currently no systematic way to identify these companies in the Medicare data.  
These providers billed both Medicare fee-for-service and Medicare Advantage plans 
for telehealth services.   
It is important to note that a Medicare billing practiceknown as incident to 
billingcreates challenges for oversight.  Incident to billing allows for services 
provided by clinical staff who are directly supervised by a practitioner to be billed 
under the supervising practitioners identification number.  Identifying the individual 
who delivered the telehealth service that is billed to Medicare is critical to program 
integrity efforts.  To address these limitations in the data, we developed measures for 
this report that aim to minimize the effect of incident to billing on the results of the 
claims analysis.   
More than 670 providers billed inappropriately for both a 
telehealth service and a facility fee for most of their visits 
A total of 672 providers billed 
for both a facility feealso 
known as an originating site  Billing for Telehealth Services 
feeand a telehealth service for 
When a beneficiary receives a telehealth 
more than 75 percent of their 
service in a facilitysuch as a hospital 
telehealth visits.  A provider 
or physicians officefrom a physician 
should not bill for both the 
or practitioner located at a separate 
facility fee and a telehealth 
location, the facility can charge 
service for the same visit.16     
Medicare a facility fee for hosting the 
telehealth service.   
Billing for both would mean that 
the provider and beneficiary  The physician or practitioner who 
were at the same physical  provides the telehealth service may not 
location when the telehealth  bill for the facility fee. 
service was provided; therefore, 
the provider is not allowed to   
deliver a telehealth service.17  
Although some providers may be billing this way in error, other s may be billing this 
way to inappropriately maximize their Medicare payments for each visit.    
These 672 providers billed for both the facility fee and a telehealth service for about 
148,000 visits, totaling more than $14.3 million for facility fees and telehealth services.  
In total, 21 providers billed for both the facility fee and a telehealth service for more 
than 1,000 visits each.  Further, 57 providers billed this way for all of their visits.  
 
 
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Examples of providers who billed for both a facility fee and a telehealth 
service 
Two providersa psychiatrist and psychologistbilled for both a facility fee and a 
telehealth service for more than 90 percent of their visits, amounting to nearly 
4,000 visits each.  These providers billed facility fees and telehealth services 
totaling approximately $1.1 million.   
 
More than 360 providers always billed telehealth services at the 
highest, most expensive level  
In total, 365 providers billed for certain telehealth services at the highest, most 
expensive level every time.18  Providers can bill certain services at different levels 
depending on the complexity of the beneficiarys condition or the duration required 
to diagnose and treat a beneficiary.   
Billing for the highest level of complexity or duration when that is not what was 
needed or provided is one scheme that unscrupulous providers use to inappropriately 
increase their Medicare payments.  Payments for the highest level range from nearly 
two times to almost eight times more than the lowest level.  This practice is often 
referred to as upcoding.  In these cases, providers may be delivering higher levels of 
services than medically necessary or billing for levels of services that were not 
rendered.   
Office visits provided via telehealth: In total, 
170 providers always billed for office visits  Office Visits 
provided via telehealth at the highest, most 
expensive level possible.  In contrast, most  170 providers always 
providers who billed for these types of visits  billed at the highest level. 
never billed at the highest level.  (See 
14 providers billed for 
Appendix B for a description of the different 
prolonged services 
levels of each of these types of services.) 
beyond the highest level 
for more than half of 
These 170 providers billed for about 34,400 
their visits. 
telehealth office visits, all at the highest level.  
Medicare fee-for-service payments for these 
 
visits totaled $2.2 million.  Two of these 
providers billed the highest level for more than 1,300 visits each.   
 
In some cases, providers billing at the highest levels were concentrated in specific 
medical practices.  In total, 21 medical practices had multiple providers who always 
billed at the highest level for telehealth office visits.  In one case, a single medical 
practice had 30 providers who always billed at the highest level. 
In addition to always billing at the highest level, 14 providers billed for additional 
time, prolonging the office visits past the highest level, for more than half of their 
visits.19  One provider billed this way for more than 90 percent of the providers 
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telehealth office visits.  Providers who bill for prolonged office visits that extend 
beyond the time at the highest level receive additional payment. 
Other types of visits provided via 
telehealth: An additional 195 providers 
always billed for other types of visits at the 
Other Visits 
highest, most expensive level.  These types of 
visits included home visits, nursing home  140 providers always 
visits, or assisted living visits that were  billed telehealth home 
provided via telehealth.20  In contrast, most  visits at the highest level. 
providers almost never billed the highest level 
41 providers always billed 
for any of these services.   
telehealth nursing home 
These 195 providers billed for about 40,300  visits at the highest level. 
visits, totaling almost $3 million in Medicare 
19 providers always billed 
fee-for-service payments.  Five of these 
telehealth assisted living 
providers billed at the highest level for more 
visits at the highest level. 
than 1,000 visits each.  One provider not only 
billed exclusively for the highest level possible 
 
of home visits, but also billed for additional 
time, prolonging the home visits past the highest level, for more than half of the visits. 
 
More than 320 providers billed for telehealth services  for more 
than 300 days of the year 
A total of 328 providers billed for telehealth services for more than 300 days of the 
year, which averages to more than 25 days per month for each provider.  Each of 
these providers billed for telehealth services for many more days, compared to the 
median of 26 days of the year for all providers who billed for telehealth services.   
Billing for telehealth for a high number of days may indicate that the provider may 
not be providing the services for which they are billing.  The 328 providers who billed 
for telehealth services for more than 300 days received a total of $65 million in 
Medicare fee-for-service payments.  In some cases, these providers were concentrated 
in specific medical practices.  Specifically, 96 of the 328 providers are a part of the 
same medical practice as at least one other provider who billed for more than 300 
days. 
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Example of providers who billed for telehealth services for more than 300 
  days of the year 
Two family medicine providers billed for telehealth services every single day from 
  March 1, 2020, to February 28, 2021.  Together, they billed for nearly 18,600 
services for slightly more than 1,800 beneficiariesaveraging to more than 10 
services for each beneficiary.  They received nearly $500,000 in Medicare fee-for-
service payments.   
Two other providerswho appear to be associated with the same telehealth 
companybilled for telehealth services every single day of the year.  Together, 
these providers billed for approximately 76,000 services for slightly more than 
4,300 beneficiariesaveraging to more than 17 services for each beneficiary.  They 
received more than $1.4 million in Medicare fee-for-service payments.  
 
 
More than 130 providers repeatedly billed Medicare fee-for-
service and a Medicare Advantage plan for the same telehealth 
service  
A total of 138 providers billed both Medicare fee-for-service and a Medicare 
Advantage plan for the same telehealth service for more than 20 percent of their 
telehealth services.21  Repeatedly billing both Medicare programs for the same service 
may indicate that providers are intentionally submitting duplicate claims to increase 
their Medicare payments. 
These 138 providers billed both programs for more than 9,000 telehealth services.  Of 
note, three providers billed both Medicare fee-for-service and a Medicare Advantage 
plan for at least 90 percent of their telehealth services.   
More than 80 providers billed for a high average number of 
hours of telehealth services per visit 
In total, 86 providers billed for an average of more than 2 hours of telehealth services 
per visit.  This is far higher than the median of 21 minutes of telehealth services per 
visit for all providers who billed for telehealth services.   
When providers bill for a high average number of hours of telehealth services per 
visit, they may be billing for unnecessary services or for services not rendered.22  This 
is one method that unscrupulous providers use to inappropriately maximize their 
Medicare payments.23   
Notably, 10 providers billed an average of 3 or more hours per visitmore than 8 
times the average for a telehealth visit.  One provider, a psychologist, billed 3 or more 
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hours for more than 150 visits.  On one occasion, this provider billed for 10 hours for 
a single visit for one beneficiary. 
Many of the providers who billed for a high average number of hours of telehealth 
services per visit billed for the same service multiple times during a single visit.  These 
providers commonly billed for multiple psychotherapy or rehabilitation sessions for 
the same patient in a single day.  For example, nine providers each billed five or more 
times for psychotherapy for several visits.  This may indicate that these providers are 
inappropriately maximizing Medicare payments by billing for services not provided or 
providing unnecessary services. 
 
Example of a provider who billed for a high number of hours of telehealth 
 
services per visit 
One mental health counselor billed an average of nearly 4 hours per visit for 37 
different visits.  This provider also frequently billed the same psychotherapy 
service eight times per visit.  This provider and six other providers who billed a 
high number of hours worked for the same chain of mental health and substance 
use recovery facilities in Florida.  
More than 70 providers billed for telehealth services for a high 
number of beneficiaries 
These 76 providers each billed for telehealth services for at least 2,000 beneficiaries in 
a year.  This is far above the median of 21 beneficiaries for all providers who billed for 
telehealth services.  These providers billed for more than 1.7 million telehealth 
services, totaling nearly $57.5 million in Medicare fee-for-service payments.  They 
most commonly billed for office visits and audio-only services.   
Two of these providers, who appear to be associated with the same telehealth 
company, each billed for more than 10,000 beneficiaries.  One of these providers 
billed for more than 27,400 beneficiariesan average of 75 beneficiaries a day if the 
provider rendered services every single day for a year.  Another provider, who did not 
appear to be associated with a telehealth company, billed for more than 4,400 
beneficiaries.  For this to occur, this provider would need to see an average of 12 new 
beneficiaries every single day for a year.  
It is highly improbable that these providers rendered telehealth services to, or were 
available to supervise telehealth services for, so many beneficiaries.  Billing for a high 
number of beneficiaries may indicate that the provider is billing for services that were 
not provided.  If these services were provided, this billing raises serious concerns 
about the quality of care.   
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In total, six medical practices were associated with multiple providers who billed for a 
high number of beneficiaries.  In one case, six providers were a part of the same 
medical practice.   
More than 60 providers commonly billed for telehealth services 
and then ordered medical equipment and supplies  
In total, 67 providers billed for telehealth services and then ordered medical 
equipment and supplies for at least half of their beneficiaries.  This is far higher than 
the median of 3 percent for all providers.24  Billing medical equipment and supplies 
for a high percentage of beneficiaries raises concern, as this practice has been linked 
to known fraud schemes. 
In total, these 67 providers billed for telehealth services and ordered medical 
equipment and supplies that amounted to a total of more than $28 million from 
Medicare fee-for-service.  These providers may be ordering unnecessary medical 
equipment and supplies for beneficiaries.  For example, providers may be billing for 
telehealth services, regardless of whether a beneficiary was ever contacted, and 
ordering medical equipment and supplies as part of a kickback scheme with suppliers.  
Of note, most of these providers specialized in internal or family medicine.     
There is added concern when providers order medical equipment and supplies 
primarily for beneficiaries with whom they do not have an established relationship.  
During the pandemic, the requirement for an in-person visit with the beneficiary 
before ordering medical equipment and supplies was waived in most instances.25  
Notably, seven providers ordered medical equipment and supplies solely for 
beneficiaries with whom they had no established relationship.  This billing pattern 
may indicate that these providers are billing for telehealth services and ordering 
medical equipment and supplies using stolen or compromised beneficiary identifiers.   
Additionally, six providers billed primarily for audio-only telehealth services before 
ordering medical equipment and supplies for beneficiaries.  This may indicate that 
providers are cold calling new beneficiaries to increase orders for medical equipment, 
supplies, and telehealth services.26  In 2021 and 2022, OIG and other law enforcement 
partners uncovered alleged kickback schemes that involved telehealth companies 
partnering with durable medical equipment companies to commit Medicare fraud.27  
In some instances, the providers allegedly billed Medicare for telehealth services that 
did not occur.  
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Examples of providers who billed for telehealth services and then ordered 
medical equipment and supplies 
 
One physician billed for telehealth and then ordered medical equipment and 
supplies for more than 400 beneficiaries, representing nearly 78 percent of their 
beneficiaries.  This physician ordered 109 different types of medical equipment and 
supplies, totaling more than $9 million.  The physician did not have an established 
relationship with any of the 400 beneficiaries and appeared to provide services 
through a telehealth company. 
 
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CONCLUSION AND RECOMMENDATIONS 
 
 
The changes to Medicare telehealth policy, along with the dramatic increase in the 
use of telehealth, underscore the importance of determining whether providers are 
billing for telehealth services appropriately and of identifying ways to safeguard the 
program against fraud, waste, and abuse.   
We identified 1,714 providers whose billing for telehealth services during the first year 
of the pandemic poses a high risk to Medicare.  Although these providers represent a 
small proportion of the approximately 742,000 providers who billed for a telehealth 
service, their billing raises concern.  For example, they may be billing for telehealth 
services that are not medically necessary or were never provided.   
These findings also highlight several ways that providers may inappropriately bill for 
telehealth services.  Further, these findings shed light on potential methods for 
safeguarding the program and protecting beneficiaries specific to telehealth.  
As permanent changes to telehealth are considered, it is essential that CMS, Congress, 
and other stakeholders incorporate targeted, appropriate safeguards to prevent, 
detect, and remediate the program integrity risks identified in this report.  Currently, 
CMS is utilizing existing tools, such as pre- and post-payment edits and the Fraud 
Prevention System edits, to address program integrity risks associated with telehealth.  
Additionally, CMS is part of the Healthcare Fraud Prevention Partnership and meets 
with OIG investigators and the Department of Justice (DOJ) to discuss fraud trends 
and coordinate on certain cases of suspected fraud.28  CMS also conducts provider 
interviews, beneficiary interviews, and medical reviews to determine whether services 
billed were medically necessary.  However, the billing practices that we identified 
demonstrate the benefit and importance of strengthening targeted oversight of 
telehealth services to protect the Medicare program and beneficiaries against fraud, 
waste, and abuse.29   
We recommend that CMS: 
Strengthen monitoring and targeted oversight of telehealth 
services  
To effectively target program integrity efforts, CMS and its contractors should closely 
monitor telehealth services on an ongoing basis to identify providers who pose a risk 
to the program.  CMS could use the measures in this report, and others it deems 
appropriate, when designing its claims analysis to strengthen its oversight of 
telehealth services.  Further, as program integrity risks evolve, stakeholders can use 
these findings to inform future oversight efforts.   
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OEI-02-20-00720  Conclusion and Recommendations | 13     
 
In addition, CMS currently sends reports to select providers that compare their 
number of claims for certain telehealth services to national and State averages.30  
CMS could incorporate additional measures into these provider reports based on the 
program integrity risks identified in this report.  For example, it could include 
measures that focus on the extent to which providers bill for the highest, most 
expensive levels of certain telehealth services.   
CMS should also conduct targeted reviews of providers identified through the 
measures we developed, or others it deems appropriate.  These reviews could include 
close monitoring of providers billing patterns and reviews of their medical records, as 
appropriate.  These reviews could be used to recover inappropriate payments, to 
place certain providers on prepayment review, to initiate fraud investigations, or to 
develop additional claims processing edits, as necessary. 
Provide additional education to providers on appropriate billing 
for telehealth services  
The providers identified in this report billed in a manner that may indicate fraud, 
waste, or abuse.  In addition to these providers, other providers billed for telehealth 
services inappropriately but did not exceed the high thresholds we set for these 
measures.  For example, more than 18,000 providers billed both Medicare fee-for-
service and a Medicare Advantage plan for the same telehealth service at least once.  
Additionally, more than 5,700 providers billed for both a telehealth service and a 
facility fee for the same visit at least once.  One way to reduce inappropriate billing is 
to provide additional education to providers on how to correctly bill for telehealth 
services. 
CMS should conduct additional educational outreach to providers.  CMS should offer 
additional trainings and webinars on how to appropriately bill for telehealth services 
through its Medicare Learning Network.  As a part of this outreach, CMS should 
include information such as when it is appropriate to bill an originating site facility fee 
and how to avoid billing Medicare fee-for-service and a Medicare Advantage plan for 
the same service.  
Further, CMS should target specific providers with high levels of inappropriate billing 
for telehealth services and provide one-on-one education to them.  These one-on-
one training sessions should include a discussion with the provider about the 
telehealth services inappropriately billed and a review of CMS guidelines that should 
have been followed.  
 
 
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Improve the transparency of incident to services when clinical 
staff primarily delivered a telehealth service 
Identifying the individual who delivered the telehealth service that is billed to 
Medicare is critical to program integrity efforts; however, this identification is not 
possible under Medicares current billing rules.  Incident to billing allows services 
provided by clinical staff who are directly supervised by a physician or non-physician 
practitioner to be billed under the supervising practitioners identification number.  
Consequently, multiple individuals can provide telehealth services under a single 
identification number.  This billing practice makes it difficult to determine when 
telehealth services were provided by the physician or when services were rendered 
incident to a physician.   
Further, Medicare billing data would also not reveal whether an individual providing a 
service under a physicians supervision had been terminated from Medicare or 
excluded from participation from Federal health care programs.  In addition, prior OIG 
work found that incident to services provided in person were frequently delivered 
by practitioners who lacked the licenses, certifications, credentials, or training required 
for those services.31  It is important that CMS and oversight agencies are able to 
determine which provider rendered a telehealth service to a beneficiary.   
For this reason, CMS should require the use of a modifier to indicate incident to 
telehealth services when clinical staff primarily delivered the service billed under the 
supervising practitioners identification number.  To do so, CMS should create a 
service code modifier.  CMS should require that providers use this modifier on 
Medicare fee-for-service claims and Medicare Advantage encounters to identify 
incident to telehealth services. 
In addition to the modifier, CMS should also take steps to allow providers to report 
the identification number of the clinical staff who primarily delivered the service, when 
available.32  To do so, CMS should take steps to create a new field for clinical staff 
who have their own identification number to report this information.  CMS should 
work with the designated standards development organization (X12) and the National 
Uniform Claim Committee to initiate this change on the claim form.  Taking these 
steps would allow CMS to require providers to complete this field with the clinical 
staffs identification number for both Medicare fee-for-service claims and Medicare 
Advantage encounters.  
By taking these steps to increase transparency, CMS can strengthen program integrity 
efforts and enable oversight agencies to conduct more detailed analyses at the 
provider level.  This information can also be used to help monitor quality of care and 
beneficiary safety related to the use of remote supervision.33 
 
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Conclusion and Recommendations | 15     
Identify telehealth companies that bill Medicare 
Some of the providers we identified who pose a high risk appear to be associated 
with telehealth companies.  However, there is currently no systematic way to identify 
these companies in the Medicare data.  To improve oversight of telehealth services, it 
is important that CMS and other oversight agencies be able to identify providers 
associated with telehealth companies on claims and encounters.  CMS and others 
could use this information to more closely monitor these companies and identify 
companies that pose a risk to the Medicare program.  
CMS should identify telehealth companies that bill Medicare.  To do this, CMS could 
update the Medicare provider enrollment application (e.g., CMS-855B) to identify 
telehealth companies that enroll in Medicare.  Alternatively, CMS could work with the 
National Uniform Claim Committee to add a taxonomy code that identifies telehealth 
companies.  This information would allow CMS to monitor when beneficiaries receive 
services from providers associated with telehealth companies and could assist quality 
of care assessments in the future.  The Medicare Payment Advisory Commission has 
noted concerns that if beneficiaries receive services via telehealth companies from 
clinicians who are not their usual source of care, their care may become fragmented.34  
It has also noted the need to identify telehealth companies to assess appropriate 
reimbursement for services provided by telehealth companies.35    
Follow up on the providers identified in this report 
In a separate memorandum, we will refer to CMS the providers we identified as 
posing a high risk to Medicare.  CMS should review this information and take action, 
as appropriate.  
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Conclusion and Recommendations | 16     
AGENCY COMMENTS AND OIG RESPONSE
 
 
CMS concurred with our recommendation to follow up on the providers identified in 
this report, but CMS did not explicitly indicate whether it concurred with the other 
four recommendations.   
CMS did not explicitly indicate whether it concurred with our recommendation to 
strengthen monitoring and targeted oversight of telehealth services.  CMS stated that 
it will need to carefully review the issues identified to assess whether these issues 
have already been addressed, and if not, whether additional CMS actions are needed.  
In response, OIG emphasizes that this report highlights several ways that providers 
may be inappropriately billing for telehealth services and sheds light on potential 
methods specific to telehealth for safeguarding the program and protecting 
beneficiaries.  Accordingly, we encourage CMS to strengthen targeted oversight of 
telehealth services to protect the Medicare program and beneficiaries against fraud, 
waste, and abuse.  While OIG recognizes that the providers identified in this report 
represent a small percentage of the overall number of Medicare providers who billed 
for a telehealth service during the first year of the pandemic, that also means that 
targeted oversight of specific providers may be especially effective in addressing 
potential fraud, waste, and abuse related to telehealth services.  Additionally, because 
this data brief focuses on specific measures with very high thresholds, it does not 
capture all concerning billing related to telehealth services that may be occurring in 
Medicare.  Strengthening monitoring and targeted oversight could help prevent the 
number of high-risk providers from increasing in the future.   
CMS also did not explicitly indicate whether it concurred with our recommendation to 
provide additional education to providers on appropriate billing for telehealth 
services.  CMS noted that it has provided a variety of educational materials to 
promote proper billing for telehealth services and that it provides one-on-one 
education when appropriate and cost effective.  CMS stated that it will analyze OIGs 
data to determine whether additional education is necessary.  In response, OIG 
emphasizes that providing additional education to providers on how to correctly bill 
for telehealth services is one way to reduce inappropriate billing.  We appreciate that 
CMS has taken some steps toward this recommendation and encourage it to further 
build on those steps.  For example, while CMS has provided information on the 
location requirements for originating sites in a Medicare Learning Network Fact Sheet 
on telehealth services, providing additional education on when providers may or may 
not bill for the originating site facility fee can help reduce improper billing and 
payments.36  We further note that many providers billed for telehealth services 
inappropriately but did not exceed the high thresholds we set for these measures.   
CMS also did not explicitly indicate whether it concurred with our recommendation to 
improve the transparency of incident to services when clinical staff primarily 
delivered a telehealth service.  CMS acknowledged that increasing transparency of 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Agency Comments and OIG Response | 17     
incident to services could aid in program integrity efforts.  However, CMS stated 
that modifying the claim form to add a new field is not within the Agencys control 
and requires extensive system changes that may impact the entire health care system.  
CMS further stated that it does not believe that a modifier is sufficient to address 
OIGs concerns without a change to the claim form to identify the individual who 
primarily delivered the service.  In response, OIG continues to emphasize the 
importance of CMS and oversight agencies having the ability to determine which 
provider rendered a telehealth service to a beneficiary.  Accordingly, while OIG 
recognizes that modifying the claim form will take time and poses a significant 
undertaking, the need for increased transparency is important.  As a critical partner 
with multiple representatives on the National Uniform Claim Committee, we 
encourage CMS to pursue the steps listed in this report to modify the claim form.  In 
the meantime, OIG encourages CMS to use its authority to create a service code 
modifier to identify incident to services when clinical staff primarily delivered the 
service billed under a supervising practitioners identification number.   
CMS also did not explicitly indicate whether it concurred with our recommendation to 
identify telehealth companies that bill Medicare.  CMS stated that it has developed 
ways to assist with identifying telehealth companies and providers associated with 
telehealth companies.  CMS noted that if it finds additional information is necessary it 
will evaluate the feasibility and benefits of modifying the provider enrollment 
application and/or adding a taxonomy code to identify telehealth companies.  In 
response, OIG emphasizes that the findings of this report highlight the importance of 
CMS and other oversight agencies being able to identify providers associated with 
telehealth companies on claims and encounters to improve oversight of telehealth 
services. 
CMS concurred with our recommendation to follow up on the providers identified in 
this report.  CMS stated that it will review the providers identified as posing a high risk 
to Medicare and will follow up as appropriate.   
We ask that CMSin its Final Management Decisionprovide details on any plans 
and progress toward implementing our recommendations.  
For the full text of CMSs comments, see Appendix C. 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Agency Comments and OIG Response | 18     
 
METHODOLOGY 
 
 
We based this data brief on an analysis of Medicare fee-for-service claims data and 
Medicare Advantage encounter data.  We included Medicare claims from Medicare 
fee-for-service and encounters from Medicare Advantage plans from March 1, 2020, 
to February 28, 2021.  These data are similar to the data used in other reports in the 
series about Medicare beneficiaries use of telehealth during the pandemic.37   
We used the Medicare Part B fee-for-service claims from the National Claims History 
File and Medicare Advantage encounters from Part C Encounter data.  We included 
telehealth services billed by individual practitioners; we did not include telehealth 
services billed by institutional entities, such as hospitals and nursing homes.  We 
included claims and encounters that were final action and approved for payment.  
We used provider enrollment data from the National Plan and Provider Enumeration 
System.38  
Analysis of Providers Who Billed for Telehealth Services  
To conduct this analysis, we first identified the services that Medicare approved for 
telehealth during the pandemic.39  These services can be provided via telehealth or in 
person.  These services are identified using Current Procedural Terminology (CPT) 
codes and Healthcare Common Procedure Coding System (HCPCS) codes.  These 
codes are included on the claim by a provider for reimbursement purposes.  
Our analysis included virtual care services as a type of telehealth service.  These 
services are also referred to as communication technology-based services.  These 
services are always provided remotely, and include virtual check-ins, e-visits, remote 
monitoring, and telephone calls with a provider to discuss a beneficiarys medical 
condition.    
We identified other services that were provided via telehealth using a modifier (i.e., 
95, GT, GQ, or G0) or a place of service code (i.e., 02) that indicates the service was 
delivered via telehealth.40    
Next, we identified providers who billed Medicare for telehealth services.  These are 
the providers identified on the claims and encounter data as rendering the service.  
We included individual providers such as physicians and non-physician practitioners 
who billed either Medicare fee-for-service, Medicare Advantage plans, or both.41   
Program Integrity Measures 
To identify providers who pose a high risk to Medicare, we developed seven measures 
as indicators of possible fraud, waste, or abuse.  These measures focus on different 
types of billing for telehealth that providers may use to maximize their Medicare 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Methodology | 19     
payments.  We developed these measures based on analyses of Medicare data and 
input from OIG investigators.  
In total, we identified 741,759 providers who billed for a telehealth service during the 
pandemic.  For each provider, we analyzed the telehealth services they billed to 
Medicare.  For each measure, we developed thresholds that may indicate possible 
fraud, waste, or abuse.  All of the thresholds reflect extreme levelsthey are all higher 
than thresholds based on a standard technique to identify outliers, known as the 
Tukey method.42  
For each provider, we calculated the following measures:  
1. Billing for both a telehealth service and a facility fee for the majority of visits 
For each provider, we determined the percentage of visits that included both an 
originating site facility fee and a telehealth service.43  We identified providers who 
billed both an originating site facility fee and a telehealth service for more than 
75 percent of their visits; most providers never billed this way.   
2. Billing telehealth services at the highest, most expensive level every time 
For each provider, we calculated the percentage of telehealth services billed at the 
highest level for the following services: (1) office visits, (2) nursing home visits, (3) 
assisted living visits, and (4) home visits.44  We identified providers who always billed 
for telehealth services at the highest level for each of these types of services; most 
providers rarely, if ever, billed at the highest level. 
We also determined the percentage of services that were prolonged (i.e., a duration of 
time spent beyond the maximum time for the highest level of service). 
3. Billing telehealth services for a high number of days 
For each provider, we determined the total number of days worked during the 1-year 
timeframe of our analysis.  We identified providers who billed telehealth services for 
more than 300 daysfar higher than the median of 26 days.  Billing for more than 
300 days in a year averages to more than 25 days a month for each provider. 
4. Billing both Medicare fee-for-service and a Medicare Advantage plan for the 
same service for a high proportion of services 
For each provider, we calculated the percentage of services that were billed to both 
Medicare fee-for-service and a Medicare Advantage plan for the same telehealth 
service for the same beneficiary on the same date of service.45  We identified 
providers who billed both Medicare fee-for-service and a Medicare Advantage plan 
for the same service for more than 20 percent of their services; most providers never 
billed this way.   
 
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Methodology | 20     
5. Billing a high average number of hours of telehealth services per visit 
For each provider, we calculated the average number of hours of telehealth service 
provided per visit.46  We identified providers who billed more than an average of 
2 hours per visitfar higher than the median of 21 minutes.   
6. Billing telehealth services for a high number of beneficiaries 
For each provider, we calculated the number of beneficiaries for whom they had billed 
a telehealth service.  We identified providers who billed telehealth services for 2,000 
or more beneficiariesfar higher than the median of 21 beneficiaries.47   
7. Billing for a telehealth service and ordering medical equipment for many of 
their beneficiaries 
For each provider, we calculated the percentage of beneficiaries for whom they had 
billed a telehealth service and then ordered medical equipment and supplies.48  We 
focused this analysis on durable medical equipment and components, accessories, 
and supplies; orthotics and services; and prosthetics that were billed within 3 months 
of the telehealth service.  We identified providers who billed for a telehealth service 
and ordered medical equipment and supplies for at least half of their beneficiaries
far higher than the median of 3 percent of beneficiaries.  
Additionally, for each provider, we focused on the beneficiaries for whom they had 
ordered medical equipment and supplies and calculated the percentage of these 
beneficiaries for whom the provider did not have an established relationship.  To 
determine whether a beneficiary had an established relationship with a provider, we 
identified the date of the first telehealth service with the provider and looked back to 
January 2018 to determine whether the beneficiary had a prior in-person visit or other 
service with that same provider (i.e., providers in the same medical practice).   
In addition, for each provider, we focused on the beneficiaries for whom they had 
ordered medical equipment and supplies and calculated the percentage of these 
beneficiaries services that were provided audio-only.49   
Analysis of Providers Whose Billing Poses a High Risk 
We identified the providers who exceeded the threshold on at least one of seven 
measures.  These are providers whose billing is concerning and poses a high risk to 
Medicare.   
As a next step, we determined whether the providers we identified based on the 
measures described above had certain characteristics in common.  We looked at the 
most common services billed and instances where providers are a part of the same 
medical practice.50   
In addition, we identified providers who appear to be associated with telehealth 
companies by reviewing the name of the provider billing Medicare.  However, there is 
currently no systematic way to identify these companies in the Medicare data.   
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Methodology | 21     
Limitations 
We designed this study to identify telehealth providers who warrant further scrutiny. 
None of the measures that we analyzed confirm that a particular provider is engaging 
in fraudulent or abusive practices.  Any determination of fraud or an overpayment 
would require additional investigation.  Further, because we could not identify 
incident to billing, we were unable to include certain measures that could have 
captured additional fraud, waste, and abuse that may be occurring.  For example, we 
could not identify providers who were billing for more than 24 hours in a day.     
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.  
 
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Methodology | 22  APPENDIX A 
Examples of Medicare Telehealth Services  
Office Visits Virtual Care Services Behavioral Health  Nursing Home Visits
Services
Routine appointment  Telephone call to  Visit from a provider 
with a primary care  discuss a beneficiary's  Individual therapy with a beneficiary 
provider or specialist medical condition located in a nursing 
Group therapy
home 
Online interactions via 
Substance use disorder 
a patient portal Remote assistance with 
treatment
the use of a ventilator 
Remote monitoring of 
vital statistics
Preventive Services Physical,  Home Visits Hospital Visits
Occupational, and 
Annual wellness visit Visit from a provider  Hospital observation or 
Speech Therapy Visits
with a beneficiary  inpatient care
Diabetes management 
Wheelchair  located at home
training Emergency department 
management
Evaluation of ventilator  visit
Medical nutrition 
Training in use of  use for a beneficiary 
therapy Critical care 
prosthesis receiving respiratory 
consultation
Tobacco use  care at home
Evaluation of speech 
counseling
fluency
Assisted Living Visits Transitional Care  Dialysis Services Advanced Care 
Services Planning Services
Visit from a provider  End-stage renal 
with a beneficiary  Communication with  disease related  Explanation and 
located in an assisted  beneficiary or caregiver  services, such as  discussion of advance 
living facility after discharge from  monitoring of nutrition  directives with a 
hospital and counseling beneficiary and/or 
family member
Ophthalmology  Other Services
Services
Radiation treatment 
Eye examination and  management
evaluation
Evaluation of inhaler 
use
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Appendix A | 23   
APPENDIX B 
 
Billing for Various Levels of Complexity and Duration 
Office Visits 
New Patient  Established
Visit Patient Visit
Office visits represented 
48 percent of all services 
provided via telehealth   10 min     $37  5 min       $16
during the pandemic.51    20 min     $64  10 min     $36
These visits include   30 min     $93  15 min     $64
services with primary care 
 45 min     $150  25 min     $95
providers and specialists 
 60 min     $192  40 min     $131
for the purpose of 
evaluating or managing 
the beneficiarys medical condition.  The payment amount for the highest complexity 
level for new patients is five times the amount for the lowest complexity level.  For 
established patients, it is almost eight times the amount. 
Nursing Home Visits 
Initial Nursing  Subsequent 
Home Visit Visit
In the first 30 days after a 
beneficiarys admission, 
Medicare requires a   25 min     $92  10 min     $45
physician to conduct an 
 35 min     $132  15 min     $70
initial visit to assess the 
 45 min     $170  25 min     $93
beneficiarys condition, 
 35 min     $137
develop a plan of care, 
and write or verify their 
admitting orders.52  
Medicare also requires periodic physician visits to monitor and evaluate nursing 
facility residents during their stay.53  In addition, Medicare will cover physician visits 
outside of the periodic checks that are deemed medically necessary.54    
Initial nursing facility visits can range in duration from 25 to 45 minutes.  Subsequent 
nursing facility visits can range in duration from 10 to 35 minutes.  The payment 
amount for the highest complexity level for initial visits is nearly double the amount 
for the lowest complexity level.  For subsequent visits, it is about three times the 
amount. 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Appendix B | 24  Assisted Living Visits 
Medicare covers visits by 
New Patient  Established
providers to oversee or 
Visit Patient Visit
directly provide beneficiaries 
with examinations and medical 
 20 min     $56  15 min     $61
counseling in an assisted living 
setting.55  These visits must be   30 min     $81  25 min     $97
medically necessary and an   45 min     $141  40 min     $137
extension of normal   60 min     $190  60 min     $198
beneficiary care.56  Assisted   75 min     $224
living visits for new patients 
can range in duration from 20 to 75 minutes.  Assisted living visits for established 
patients can range in duration from 15 to 60 minutes.  The payment amount for the 
highest complexity level for a new patient assisted living visit is four times the amount 
for the lowest complexity level.  For established patients it is three times the amount.   
Home Visits 
A home visit is an evaluation 
and management service  New Patient  Established
Visit Patient Visit
provided by a physician to a 
beneficiary in their private 
residence.  Unlike with home   20 min     $56  15 min     $56
health services, the beneficiary   30 min     $80  25 min     $86
does not need to be confined 
 45 min     $131  40 min     $131
to their home to receive a 
 60 min     $186  60 min     $183
home visit.  Home visits for 
 75 min     $226
new patients can range in 
duration from 20 to 75 
minutes.  Home visits for established patients can range in duration from 15 to 
60 minutes.  The payment amount for the highest complexity level for new patients is 
four times the amount for the lowest complexity level.  For established patients, it is 
about three times the amount. 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Appendix B | 25  DATE:  July 29, 2022 
TO:  Gregory E. Demske 
Acting Principal Deputy Inspector General 
Office of Inspector General 
FROM:  Chiquita Brooks-LaSure 
Administrator 
Centers for Medicare & Medicaid Services 
SUBJECT:  Office of Inspector General (OIG) Draft Data Brief: Medicare Telehealth Services 
During the First Year of the Pandemic: Program Integrity Risks (OEI-02-20-
00720) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
CMS serves the public as a trusted partner and steward, dedicated to advancing health equity, 
expanding coverage, and improving health outcomes. Consistent with these goals, CMS issued 
waivers to prevent gaps in access to care for patients affected by the COVID-19 public health 
emergency (PHE), including waivers for services furnished via telehealth. The changes to 
payment and coverage policies were intended to allow health care providers maximum flexibility 
to minimize the spread of COVID-19 among Medicare beneficiaries, health care personnel, and 
the community at large and increase capacity to address the needs of their patients. 
On March 17, 2020, CMS announced the expansion of telehealth services on a temporary and 
emergency basis pursuant to waiver authority added under section 1135(b)(8) of the Social 
Security Act by the Coronavirus Preparedness and Response Supplemental Appropriations Act, 
2020 (Pub. L. 116-123, March 6, 2020). Beginning on March 6, 2020, and for the duration of the 
COVID-19 PHE, Medicare pays for telehealth services, including office, hospital, and other 
visits furnished by physicians and other practitioners to patients located anywhere in the country, 
including in a patients place of residence. In the context of the COVID-19 PHE, CMS 
recognized that the use of telehealth could help address new challenges regarding potential 
exposure risks, for people with Medicare, health care providers, the community at large. To 
facilitate the use of telecommunications technology as a safe substitute for in-person services, 
CMS, on a temporary interim final basis, added many services to the list of eligible Medicare 
telehealth services, eliminated frequency limitations and other requirements associated with 
particular services furnished via telehealth, and clarified several payment rules that apply to other 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Agency Comments B | 26 services that are furnished using telecommunications technologies that can reduce exposure 
risks.1 
CMS recognizes the importance of analyzing the impact of these changes, and, as such, 
immediately evaluated the waivers and flexibilities issued by the Agency to determine the 
potential for fraud, waste, and abuse in the Medicare program. This process included identifying 
program integrity risks and vulnerabilities associated with the waivers and flexibilities; 
prioritizing those with the largest potential for financial loss, beneficiary harm and/or likelihood 
of occurrence; and creating mitigations that addressed these program integrity risks and 
vulnerabilities, including those related to telehealth. 
One such mitigation strategy has been the continued use of data analytics to identify potential 
program integrity risks. CMS has continued throughout the PHE to analyze claims data to 
monitor, trend, and respond to existing telehealth fraud schemes and to detect and respond to 
potential new emerging fraud schemes. CMS uses a robust program integrity strategy to reduce 
and prevent Medicare improper payments, which includes the use of the Fraud Prevention 
System (FPS). The FPS is a predictive analytics technology that runs sophisticated algorithms 
against Medicare Fee-For Service (FFS) claims nationwide. When FPS models identify aberrant 
activity or patterns, the system automatically generates and prioritizes leads for further review 
and investigation by Unified Program Integrity Contractors (UPICs). Based on the results of all 
information collected, the UPICs coordinate with CMS and the Medicare Administrative 
Contractors in taking appropriate administrative action to recover improper payments and 
prevent future loss of funds, or the UPICs refer the case to law enforcement. 
Additionally, CMS has supported our federal law enforcement partners throughout the PHE on 
various fraud schemes including those related to telehealth. CMS continues to meet regularly 
with law enforcement to discuss new cases, fraud referrals, active UPIC and law enforcement 
cases, and paths for various administrative actions. 
CMS has also taken action to prevent improper Medicare payments by educating health care 
providers and suppliers on proper billing. For example, CMS has undertaken a number of 
stakeholder calls including open door forums and Medicare Learning Network calls, as well as 
published numerous pieces of subregulatory guidance designed to educate practitioners on the 
additional telehealth flexibilities, including how to appropriately bill for these services.2 
The OIGs recommendations and CMS responses are below. 
OIG Recommendation  
The OIG recommends that CMS strengthen monitoring and targeted oversight of telehealth 
services.  
1 The list of these eligible telehealth services is published on the CMS website at 
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html. 
2 Open Door Forum Podcast and Transcripts available at: https://www.cms.gov/Outreach-and-
Education/Outreach/OpenDoorForums/PodcastAndTranscripts; COVID-19 Frequently Asked Questions (FAQs) on 
Medicare Fee-For-Service (FFS) Billing available at: https://www.cms.gov/files/document/03092020-covid-19-faqs-
508.pdf; Physician Fee Schedule Proposed Rule: Understanding 4 Key Topics Listening Session, August, 13, 2020.
Available at: https://www.cms.gov/outreach-and-educationoutreachnpcnational-provider-calls-and-events/2020-08-
13; CMS.gov Current Emergencies webpage available at: https://www.cms.gov/About-CMS/Agency-
Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
Agency Comments B | 27
OEI-02-20-00720  CMS Response  
The providers identified by the OIG and their total associated Medicare FFS payments represent 
a small portion of the services furnished via telehealth during the first year of the PHE
representing approximately two tenths of a percent of all providers who billed for telehealth and 
approximately 2.5 percent of all Medicare FFS payments for telehealth services. While these are 
relatively small percentages, CMS takes these findings seriously and appreciates the OIGs 
review in this area. Given that this report was conducted outside of CMSs and law enforcement 
entities program integrity efforts, CMS will need to carefully review the issues identified to 
assess whether these issues have already been addressed, and if not, whether additional CMS 
actions are needed. CMS looks forward to receiving details on these issues.  
CMS will review the providers identified as posing a high risk to Medicare against those 
telehealth providers already identified by CMS and within the context of the larger program 
integrity strategy, and determine whether any additional monitoring or oversight of telehealth 
services is necessary.  
OIG Recommendation  
The OIG recommends that CMS provide additional education to providers on appropriate billing 
for telehealth services.  
CMS Response 
As stated above, CMS has provided a variety of educational materials to promote proper billing 
for telehealth services. OIG specifically states that CMS should include information such as 
when it is appropriate to bill an originating site facility fee and how to avoid billing Medicare 
FFS and a Medicare Advantage plan for the same service. CMS has provided information on the 
requirements for originating sites as well as how to check Medicare eligibility which shows 
whether a beneficiary is enrolled in a Medicare Advantage plan, to facilitate proper submission 
of claims.3, 4 OIG also suggests that CMS should target specific providers with high levels of 
inappropriate billing for telehealth services and provide one-on-one education to them. CMS 
provides one-on-one education when appropriate and cost effective. CMS will analyze OIGs 
data and determine whether additional education, including one-on-one education, is necessary.   
OIG Recommendation  
The OIG recommends that CMS improve the transparency of incident to services when 
clinical staff primarily delivered a telehealth service.  
CMS Response 
CMS acknowledges that increasing transparency of incident to services could aid in program 
integrity efforts; however, modifying the claim form to add a new field is not within the 
Agencys control. As mentioned in the full recommendation in the report, modification of the 
claim form is a function of the designated standards maintenance organization. Modifications to 
the claim form are a significant undertaking and require extensive system changes that impact 
the entire healthcare system. Therefore, this process requires industry consensus and is not based 
strictly on Medicare need or preference.  
3 Medicate Learning Network (MLN) Fact Sheet: Telehealth Services (June 2021) available at: 
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf  
4 MLN Fact Sheet: Checking Medicare Eligibility (October 2021) available at: 
https://www.cms.gov/files/document/checking-medicare-eligibility.pdf 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
Agency Comments B | 28
OEI-02-20-00720  OIG also suggests that CMS require a modifier to indicate incident to telehealth services. CMS 
does not believe that a modifier is sufficient to address the OIGs concerns without the change to 
the claim form to identify the individual who primarily delivered the service.     
OIG Recommendation 
The OIG recommends that CMS identify telehealth companies that bill for Medicare. 
CMS Response 
Based on the OIGs findings, the risk associated with telehealth companies is unclear. As stated 
above, CMS has a robust program integrity strategy. As part of this strategy, CMS has developed 
ways to assist with identifying telehealth companies and providers associated with telehealth 
companies. Consistent with Recommendation 5 below, CMS will review the providers identified 
as posing a high risk to Medicare against those telehealth providers already identified by CMS, 
and within the context of the larger program integrity strategy, and determine whether additional 
information is necessary to identify telehealth companies. If additional information is necessary, 
CMS will evaluate the feasibility and benefits of modifying the provider enrollment application 
and/or adding a taxonomy code to identify telehealth companies.  
OIG Recommendation 
The OIG recommends that CMS follow up on the providers identified in the report. 
CMS Response 
CMS concurs with this recommendation. CMS will review the providers identified as posing a high 
risk to Medicare against those telehealth providers already identified by CMS, and within the 
context of the larger program integrity strategy. If necessary, CMS will follow up as determined 
appropriate.  
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Agency Comments B | 29    
 
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Judy Kellis served as the team leader for this study.  Others in the Office of Evaluation 
and Inspections who conducted the study include Alexis Mills and John Gordon.  
Office of Evaluation and Inspections staff who contributed to the study include Miriam 
Anderson, Robert Gibbons, Eddie Baker, Jr., and Michael Novello.  
This report was prepared under the direction of Jodi Nudelman, Regional Inspector 
General for Evaluation and Inspections in the New York regional office, and Nancy 
Harrison and Meridith Seife, Deputy Regional Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
   
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OEI-02-20-00720  Acknowledgments and Contact | 30     
 
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1 HHS and CMS were able to temporarily expand access to telehealth because of their waiver authority under section 1135 of 
the Social Security Act, subsequent legislation, and the Secretarys declaration of a public health emergency due to COVID-19.  
The public health emergency was announced on January 31, 2020.  See HHS, Determination that a Public Health Emergency 
Exists, January 31, 2020, accessed at https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx on April 
8, 2022.  See also Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, accessed at 
https://www.congress.gov/bill/116th-congress/house-bill/6074/text/rds on November 23, 2021.  See also Families First 
Coronavirus Response Act, accessed at https://www.congress.gov/bill/116th-congress/house-bill/6201/text on April 15, 2022.  
See also CARES Act, accessed at https://www.congress.gov/bill/116th-congress/house-bill/748/text on November 23, 2021. 
2 CMS, Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs), July 2020.  Accessed at 
https://www.cms.gov/files/document/provider-burden-relief-
faqs.pdf#:~:text=On%20March%2030%20CMS%20suspended%20most%20Medicare%20Fee-For-
Service,potentially%20selected%20for%20review%20will%20also%20be%20applied on December 28, 2021.  
3 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic, 
OEI-02-20-00520, March 2022. 
4 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established 
relationship, OEI-02-20-00521, October 2021; OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries 
During the First Year of the COVID-19 Pandemic, OEI-02-20-00520, March 2022; OIG, Certain Medicare Beneficiaries, Such as 
Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use Telehealth During the First Year of the COVID-19 
Pandemic, OEI-02-20-00522, September 2022; Pandemic Response Accountability Committee, Telehealth Services in Select 
Federal Health Care Programs, forthcoming.  
5 For the purposes of this report, we refer to the services that can be delivered either via telehealth or in-personas well as 
services that are always provided remotelyas telehealth services.   
6 These services are also referred to as communication technology-based services.  For the purposes of this report, we refer to 
them as virtual care services.  CMS does not include communication technology-based services in its formal definition of 
telehealth services. 
7 For example, prior to the pandemic, beneficiaries were allowed to use telehealth services to address substance use disorder 
or end-stage renal disease from their home and in urban areas.  In addition, beginning in 2020, beneficiaries enrolled in 
Medicare Advantage plans were allowed to use telehealth services in their home and in urban areas. 
8 For the purposes of this study, we included telehealth services that Medicare had approved for payment as of February 28, 
2021.   
9 Prior to the pandemic, beneficiaries could receive certain services, such as virtual check-ins, through audio-only. 
10 For more information, see DOJ, Federal Law Enforcement Action Involving Fraudulent Genetic Testing Results in Charges 
Against 35 Individuals Responsible for Over $2.1 Billion in Losses in One of the Largest Health Care Fraud Schemes Ever 
Charged, September 27, 2019; see also DOJ, National Health Care Fraud and Opioid Takedown Results in Charges Against 
345 Defendants Responsible for More Than $6 Billion in Alleged Fraud Losses, September, 30, 2020; see also DOJ, DOJ 
Announces Coordinated Law Enforcement Action To Combat Health Care Fraud Related to COVID-19, May 26, 2021; see also 
DOJ, Nationwide Coordinated Law Enforcement Action to Combat Telemedicine, Clinical Laboratory, and Durable Medical 
Equipment Fraud, July 20, 2022. 
11 The analysis includes billing by individual practitioners but not by institutions, such as hospitals. 
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Endnotes | 31     
 
12 If these services were provided as billed, it raises concerns about the quality of services.  For example, providers who billed 
for a high number of days or a high number of beneficiaries may not be providing proper supervision or spending an adequate 
amount of time with each beneficiary. 
13 This amount includes Medicare payments, beneficiary copays and deductible amounts, and any third-party payments for 
services billed to Medicare-fee-for-service. 
14 For the purposes of this report, we refer to the organization that billed Medicare for the telehealth service as the medical 
practice. 
15 These companies are also referred to as direct-to-consumer telehealth vendors.  A provider may be associated with more 
than one telehealth company.  For more information on telehealth companies, see University of Michigan Institute for 
Healthcare Policy and Innovation, Telehealth Research Incubators Research Snapshots, July 2021.  Accessed at 
https://ihpi.umich.edu/sites/default/files/2021-08/Telehealth_Research_Snapshots_Databook_2021.pdf on January 7, 2022.   
16 Only the physician or practitioner may receive payment for the telehealth service, and only the facility may bill for the facility 
fee.  The physician or practitioner who provides the telehealth service may not bill or receive payment for the facility fee.  See 
42 CFR  414.65(a)(1) and (b)(2). 
17 See CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, p. 62.  Accessed at 
https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf, on December 28, 2021.  
18 We focused our analysis on certain types of services that providers can bill for at different levels depending on their 
complexity or duration; these services include office visits, nursing home visits, assisted living visits, and home visits.   
19 To bill for an office visit that was prolonged, providers bill one or more procedure codes that indicate the extra number of 
minutes that the service was prolonged.  These procedure codes have specific payment amounts associated with them. 
20 Five of these providers always billed for the highest level for two types of visits, such as assisted living visits and home visits. 
21 A total of 18,034 providers billed both Medicare fee-for-service and Medicare Advantage for the same telehealth service for 
the same beneficiary on the same date of service at least once.  Although each of these providers billed this way at least once, 
we did not consider them high risk unless they billed this way for more than 20 percent of their claims and encounters.  
22 We analyzed hours per visit to avoid the problem of incident to billing.  Regardless of whether the practitioner or clinical 
staff are providing services incident to the practitioner, it is concerning that they are consistently billing for telehealth visits 
that last longer than 2 hoursespecially in relation to the median length of 21 minutes per visit.  
23 CMS, Medicare Fraud & Abuse: Prevent, Detect, Report, January 2021.  Accessed at https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf on April 22, 2021.  
24 We focused this analysis on providers who ordered medical equipment and supplies billed to Medicare fee-for-service.  
Medicare Advantage plans are not required to report information about the ordering provider to Medicare. 
25 85 Fed. Reg. 19230 (Apr. 6, 2020). 
26 In these cases, the providers billed for the telehealth services.  For more information on the differences between telehealth 
fraud and telefraud, see OIG, Principal Deputy Inspector General Grimm on Telehealth, February 26, 2021.  Accessed at 
https://oig.hhs.gov/coronavirus/letter-grimm-02262021.asp on February 10, 2022. 
27 These schemes also involved genetic testing laboratories, and pharmacies.  See DOJ, National Health Care Fraud 
Enforcement Action Results in Charges Involving Over $1.4 Billion in Alleged Losses, September 17, 2021; see also DOJ, 
Nationwide Coordinated Law Enforcement Action to Combat Telemedicine, Clinical Laboratory, and Durable Medical 
Equipment Fraud, July 20, 2022.  
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Endnotes | 32     
 
28 For more information on CMSs Fraud Prevention System and Healthcare Fraud Prevention Partnership, see 
https://www.cms.gov/About-CMS/Components/CPI/CPI-Investing-In-Data-and-Analytics. 
29 OIG has additional evaluations and audits underway examining telehealth in Medicare to help further inform program 
policies and oversight.  See the HHS-OIG Work Plan, which can be found at https://oig.hhs.gov/reports-and-
publications/workplan/index.asp. 
30 These reports are limited to Medicare fee-for-service claims.  Further information on the Comparative Billing Reports that 
CMS sends to providers can be found at https://cbr.cbrpepper.org/home. 
31 OIG, Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services, OEI-09-06-00430, August 
2009. 
32 There may be clinical staff without an individual identification number billing incident to a supervising practitioner.  In 
these instances, we would not expect providers to report the clinical staffs identification number.  
33 The Medicare Payment Advisory Commission has noted that there are quality of care and beneficiary safety concerns related 
to the use of remote supervision when the supervising practitioner is not physically available to help if necessary.  See 86 Fed. 
Reg. 64996 (Nov. 19, 2021). 
34 Medicare Payment Advisory Commission, Report to Congress March 2021, Chapter 14: Telehealth in Medicare after the 
coronavirus public health emergency.  Accessed at https://www.medpac.gov/wp-
content/uploads/2021/10/mar21_medpac_report_ch14_sec.pdf on January 4, 2022. 
35 Telehealth companies may have lower costs than providers who see beneficiaries in person.  See Medicare Payment Advisory 
Commission, Report to Congress March 2021, Chapter 14: Telehealth in Medicare after the coronavirus public health emergency.  
Accessed at https://www.medpac.gov/wp-content/uploads/2021/10/mar21_medpac_report_ch14_sec.pdf on January 4, 2022. 
36 CMS, Telehealth Services, June 2021.  Accessed at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf on August 11, 2022. 
37 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established 
relationship, OEI-02-20-00521, October 2021; OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries 
During the First Year of the COVID-19 Pandemic, OEI-02-20-00520, March 2022; OIG, Certain Medicare Beneficiaries, Such as 
Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use Telehealth During the First Year of the COVID-19 
Pandemic, OEI-02-20-00522, September 2022. 
38 We also supplemented this information with data from other sources, such as CMS contractor data and the Medicare 
Provider Enrollment, Chain, and Ownership System.  
39 The codes used in the analysis include those on the list available on the CMS website as of February 28, 2021, which can be 
found at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.  These codes also 
include the communication technology-based servicesreferred to in this report as virtual care servicesthat were allowed 
during the first year of the pandemic.  See 85 Fed. Reg. 19230 (Apr. 6, 2020) and 84472 (Dec. 28, 2020). 
40 We included all virtual care services as being provided via telehealth as they can only be provided remotely. 
41 We included professional services billed to Medicare fee-for-service and Medicare Advantage.  We did not include telehealth 
services provided directly by institutional entities, such as hospitals and nursing homes.   
42  The Tukey method identifies outliers that are above the 75th percentile plus three times the interquartile range. 
43 This analysis included providers who billed 10 or more visits.  Further, this analysis includes only individual providers that 
billed for both a facility fee and a telehealth service.  In some instances, an institutional provider, such as a hospital outpatient 
department, is able to bill for both the facility fee and a telehealth service for the same visit.  Such providers were not included 
 
Data Brief: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks 
OEI-02-20-00720  Endnotes | 33     
 
in this analysis.  For more detail, see CMS, COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) 
Billing.  Accessed at https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf on December 28, 2021. 
44 Some procedures may be billed with more than one service unit in the same visit.  For the purposes of this report, we 
considered one service unit to be one service.  In addition, this analysis included providers who billed 50 or more services.  
45 This analysis included providers who billed 50 or more services.   
46 This analysis included providers with 25 or more telehealth visits.  It did not include services that take more than 100 minutes 
and psychological testing and evaluation procedures.  To calculate the average number of hours of services for each visit, we 
used the median number of minutes for each service provided by CMS.  For more information on CMSs calculation of the 
median number of minutes per service, see https://www.cms.gov/medicaremedicare-fee-service-
paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1751-f. 
47 When determining this threshold, we considered other research on provider caseload size.  See J. Altschuler, D. Margolius, T. 
Bodenheimer, and K. Grumbach, Estimating a reasonable patient panel size for primary care physicians with team-based task 
delegation. Annals of Family Medicine, Vol. 10, No. 5, 2012, p. 396. 
48 This analysis included providers with 50 or more beneficiaries.   
49 We focused on the six telehealth services that can be identified as being provided through audio-only.  We did not include 
the other telehealth services that may be provided through audio-only because it cannot be distinguished whether they were 
provided as audio-only services or as audio-video services. 
50 We determined that providers worked for the same medical practice if they had the same billing National Provider Identifier 
on their claims and encounters. 
51 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established 
relationship, OEI-02-20-00521, October 2021. 
52 CMS, CMS Manual System: Nursing Facility Services (Codes 9930499318), April 2008.  Accessed at 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1489CP.pdf on March 19, 2021. 
53 CGS Administrators, Fact Sheet: Subsequent Nursing Facility Care, February 2019.  Accessed at 
https://www.cgsmedicare.com/partb/mr/pdf/99307.pdf on March 19, 2021. 
54 Ibid. 
55 Noridian, Home and Domiciliary Visits, August 2019.  Accessed at 
https://med.noridianmedicare.com/web/jfb/specialties/em/home-and-domiciliary-visits on March 19, 2021. 
56 Ibid. 
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OEI-02-20-00720  Endnotes | 34