Department of Health and Human Services 
O  ffice of Inspector General 
 
 
 
Toolkit:  
Analyzing Telehealth Claims to 
Assess Program Integrity Risks 
 
Ann Maxwell  
Deputy Inspector General 
   for Evaluation and Inspections 
April 2023, OEI-02-20-00723   
U. S. Department of Health and Human Services 
Office of Inspector General 
 
April 2023, OEI-02-20-00723 
 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity 
Risks   
What is the toolkit? 
This toolkit provides detailed information on methods to analyze telehealth claims to 
identify program integrity risks associated with telehealth services.  It is based on the 
methodology that the Office of Inspector General (OIG) developed for the report 
Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity 
Risks (OEI-02-20-00720), which identified Medicare providers whose billing for telehealth 
services poses a high risk to Medicare.1  To address this risk, OIG called for targeted 
oversight of telehealth services. 
This toolkit is intended to assist public and private sector partnerssuch as Medicare 
Advantage plan sponsors, private health plans, State Medicaid Fraud Control Units, and 
other Federal health care agenciesin analyzing their own telehealth claims data to 
assess program integrity risks in their programs.   
Gaining a better understanding of the program integrity risks associated with telehealth 
services can help policymakers and stakeholders develop necessary safeguards and 
address individual cases of potential fraud, waste, and abuse.  Doing so will help ensure 
that the benefits of telehealth are realized while minimizing risk in an effective and 
efficient manner. 
Why did OIG create the toolkit? 
The COVID-19 pandemic changed how patients visit and interact with their health care 
providers.  The use of telehealth services grew dramatically during the first year of the 
pandemic and is now an important part of our health care system.  Notably, Medicare 
beneficiaries used 88 times more telehealth services during the first year of the 
pandemic than in the year prior, with more than 2 in 5 Medicare beneficiaries using 
telehealth services in that year.2  Medicaid and private health plans also experienced 
exponential growth in the use of telehealth.3  In addition, certain groups, including those 
_____________________________________________________________________________________________________________________________ 
1 OIG, Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-
20-00720, September 2022.  
2 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. 
3 Government Accountability Office, CMS Should Assess Effect of Increased Telehealth Use on Beneficiaries' 
Quality of Care, GAO-22-104700, March 2022.  See also FAIR Health, Monthly Telehealth Regional Tracker, 
 
   
in medically underserved populationssuch as Hispanic beneficiarieswere more likely 
to use telehealth than were other groups in Medicare.4 
However, along with the dramatic increases in use there have been concerns about 
fraud, waste, and abuse.  Most recently, as part of the extension of telehealth in 
Medicare, lawmakers highlighted the need for further study on telehealth and Medicare 
program integrity.5 
As one of the lead Federal agencies fighting health care fraud, OIG is committed to 
supporting public and private partners in their efforts.  In response to requests from 
stakeholders, OIG is providing this toolkit as an additional resource to support the 
oversight of telehealth.6  Through the use of proactive, data-driven analyses, including 
measures such as those detailed in this toolkit, public and private partners can more 
effectively identify potential fraud, waste, and abuse schemes in their health care 
programs.7 
What does the toolkit include? 
The goal of this toolkit is to provide an approach to analyzing claims data for telehealth 
to identify areas in which additional safeguards may be necessary.  The analysis can also 
help identify providers whose billing may pose a risk and warrant further scrutiny. 
The toolkit includes detailed descriptions of seven data analysis measures that can be 
applied to the users own data.  Users can also modify the measures to meet their 
individual needs, such as identifying providers at varying levels of risk. 
KG
 
 
 
_____________________________________________________________________________________________________________________________ 
April 2020.  Accessed at https://s3.amazonaws.com/media2.fairhealth.org/infographic/telehealth/apr-
2020-national-telehealth.pdf on November 7, 2022. 
4 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.  
5 Consolidated Appropriations Act, 2023.  Accessed at 
https://www.appropriations.senate.gov/imo/media/doc/JRQ121922.PDF on January 5, 2023. 
6 In response to a recent request for information, stakeholders informed OIG that they find insight into 
our report methodologies, and toolkits, helpful.  See HHS OIG, Request for Information: Modernization 
Initiative To Improve HHS-OIG Public Resources.  Accessed at Modernization Initiative To Improve Public 
Resources | Office of Inspector General | Government Oversight | U.S. Department of Health and Human 
Services (hhs.gov) on January 12, 2023. 
7 Healthcare Fraud Prevention Partnership, Fraud, Waste, and Abuse in the Context of COVID-19, White 
Paper, January 2022.  Accessed at HFPP Fraud, Waste, and Abuse in the Context of COVID-19 White Paper 
(cms.gov) on January 12, 2023.  
   
BACKGROUND 
 
OIG has conducted extensive work on telehealth services.  As a part of this work, OIG 
identified program integrity risks associated with telehealth.  One report provided insights 
on telehealth use and program integrity risks across health care programs in six Federal 
agencies.  The report identified risks that were similar across multiple Federal programs and 
safeguards that could strengthen program integrity.  These safeguards included conducting 
additional and ongoing monitoring of telehealth services.8  Exhibit 1 highlights OIGs reports 
on telehealth.   
This toolkit is based on a report, Medicare Telehealth Services During the First Year of the 
Pandemic: Program Integrity Risks (OEI-02-20-00720), for which we developed seven 
program integrity measures as indicators of possible fraud, waste, and abuse.  These 
measures focus on different types of billing for telehealth that providers may use to 
inappropriately maximize payments.  We developed these measures by working with OIG 
investigators and by conducting extensive data analyses.  We based this review on an 
analysis of both Medicare fee-for-service claims and Medicare Advantage encounter data.   
This toolkit includes instructions for how users can apply these seven measures to their own 
telehealth claims data.  The resulting information can help users identify areas of risk for 
which additional safeguards may be needed or identify providers who warrant further 
scrutiny.   
The toolkit includes the following two sections: (1) Analysis Steps and (2) Program Integrity 
Measures.   
   
_____________________________________________________________________________________________________________________________ 
8 This report summarizes program integrity risks across six selected health care programs during the pandemic 
and was issued by the Pandemic Response Accountability Committee.  See Pandemic Response Accountability 
Committee, Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During 
the Pandemic, December 2022.  Accessed at What We Learned about Federal Telehealth Programs during the First 
Year of the Pandemic | Pandemic Oversight on January 12, 2023. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Background | 4    
Exhibit 1  OIG Reports on Telehealth Use in Medicare During the Pandemic 
 
 
 
As a part of its series of reports on telehealth, OIG identified program integrity risks associated with 
telehealth services, examined the use of telehealth in Medicare, and analyzed the characteristics of 
beneficiaries who used telehealth during the pandemic.  Click on the icons below to see the reports.  
Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks,OEI-
02-20-00720 
This data brief describes providers billing for telehealth services and identifies ways to safeguard 
Medicare from fraud, waste, and abuse related to telehealth.   
Key Takeaway: Our findings demonstrate the importance of effective, targeted oversight of telehealth 
services to ensure that the benefits of telehealth are realized while minimizing risk. 
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 
This data brief examines the characteristics of beneficiaries who used telehealth during the first year of 
the pandemic and sheds light on how the temporary expansion of telehealth affected different groups 
of beneficiaries. 
Key Takeaway: Beneficiaries in urban areasas well as dually eligible, Hispanic, younger, and female 
beneficiarieswere more likely than others to use telehealth in Medicare. 
Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of 
the COVID-19 Pandemic, OEI-02-20-00520 
This data brief provides insight into the use of telehealth in both Medicare fee-for-service and Medicare 
Advantage during the first year of the COVID-19 pandemic, from March 2020 through February 2021. 
Key Takeaway: Over 28 million Medicare beneficiaries used telehealth during the first year of the 
pandemic.  This was more than two in five Medicare beneficiaries.  
Most Medicare beneficiaries received telehealth services only from providers with whom they had 
an established relationship, OEI-02-20-00521 
This data snapshot provides information to policymakers and other stakeholders about the relationship 
between beneficiaries and providers for telehealth services. 
Key Takeaway: Eighty-four percent of beneficiaries received telehealth services only from providers 
with whom they had an established relationship.  
Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs 
During the Pandemic, OEI-02-22-00150 
This reportissued by the Pandemic Response Accountability Committee Health Care Subgroup
provides policymakers and stakeholders with information about the nature of telehealth and its use 
across selected health care programs in six Federal agencies during the first year of the pandemic.  It 
also provides insights into the program integrity risks associated with telehealth and safeguards that 
could strengthen oversight in these programs.  
Key Takeaway: All selected programs experienced dramatic increases in the use of telehealth during 
the first year of the pandemic.  Additionally, OIGs identified several program integrity risks associated 
with billing for telehealth services that were similar across multiple health care programs. 
 
 
 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Background | 5    
ANALYSIS STEPS 
This section provides the steps that can be taken to analyze claims for telehealth 
services.  The goal of the analysis is to identify program integrity risks and providers 
whose billing poses a high risk and warrants further scrutiny. 
 
Steps for Analyzing Telehealth Claims 
1.  Review program policies 
Before beginning the analysis, it is important to be familiar with the payment and 
coverage policies of the program being reviewed.  For example, it is necessary to 
know which services can be provided using telehealth and how these services are 
identified in the claims data. 
This toolkit is based on Medicare fee-for-service payment and coverage policies for 
telehealth services during the first year of the COVID-19 pandemic (March 2020 
through February 2021).  Other programs policies may differ.  Medicare policies may 
also change over time. 
2. Collect claims data  
The next step is to identify the claims for telehealth services.  The process for 
identifying telehealth claims may vary according to the coverage and billing policies 
of the program.  This toolkit is intended for use with claims data from individual 
providers, such as physician and non-physician practitioners. 9 
For Medicare, only certain services may be provided using telehealth.  We focused 
our analysis on these services.  They include services such as office visits with primary 
care providers or specialists; behavioral health services; and preventive 
services, among others.  Because these services may be provided using telehealth or 
in person, we used the modifier or the place of service code to identify claims for 
telehealth services.  During the COVID-19 pandemic, Medicare claims for telehealth 
services have a modifier of 95, GQ, or G0 or a place of service code of 02 to indicate 
that the service was delivered via telehealth.10  A complete list of services that may be 
provided using telehealth under Medicare is available for download on the 
_____________________________________________________________________________________________________________________________ 
9  The toolkit is not intended for use with claims data from institutions, such as hospitals and nursing homes.  
10 Modifier 95 can be used to identify Medicare claims for telehealth services through the later of the end of the 
year in which the Public Health Emergency ends or the 2023 calendar year.  87 Fed. Reg. 69404 (Nov. 18, 2022).     
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Analysis Steps | 6    
Centers for Medicare & Medicaid Services (CMS) website at https://www.cms.gov/me
dicare/medicare-general-information/telehealth/telehealth-codes.11   
In addition, we included in our analysis claims for virtual care services.  Virtual care 
services include virtual check-ins, e-visits, remote monitoring, and telephone calls 
with a provider to discuss a patients medical condition.  They are always provided 
remotely, so we included all claims for these services, regardless of the modifier and 
place of service codes.  A complete list of these codes is available in Appendix A.  We 
recommend that users limit their analysis to paid or final claims.  For analysis of the 
Medicare data, we included claims and encounters that were final action (meaning 
that it was the most recent version of the claim) and approved for payment.   
3. Conduct quality assurance checks  
Before using the measures, it is important to conduct quality assurance checks on the 
data.  There are many ways to conduct these checks.  The most appropriate methods 
depend on the data.   
One essential step is to test the completeness and accuracy of certain key fields within 
the data, including: 
  identification number of the provider who rendered the service; 
  identification number of the billing provider associated with the service; 
  identification number for the patient who received the service; 
  date of the service; 
  procedure code billed; 
  quantity of service units billed; and  
  modifiers or place of service codes attached to the service.  
It is also important to check the data for erroneous values.  For example, we checked 
the Medicare claims for improbable values in key fields and took steps, as 
appropriate, such as excluding claims with beneficiary identification numbers equal to 
zero.   
 
 
 
_____________________________________________________________________________________________________________________________ 
11 Note that this list is updated annually, and procedure codes approved for telehealth may change from year to 
year.    
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Analysis Steps | 7    
4. Analyze data to identify program integrity risks 
The next step is to conduct the data analysis to identify program integrity risks.  The 
measures in this toolkit are intended to be a starting point for analysis of telehealth 
claims and are based on patterns in the Medicare claims data during the first year of 
the COVID-19 pandemic.  See the seven program integrity measures we used in the 
next section.  
Billing patterns in other data may be different from those in Medicare data, so it may 
be necessary to adjust the analysisespecially the thresholdsto identify providers 
who pose a risk in different programs.  For example, we considered providers who 
billed telehealth services for 2,000 or more Medicare beneficiaries during a year to be 
high risk.  This number is far higher than the median of 21 Medicare beneficiaries for 
our data.  In a program that is significantly smaller than Medicare, a threshold of 
2,000 patients may be too high.  It is important to review measures of central 
tendency (e.g., mean and median) and distribution, including outliers, to understand 
the data and select a threshold that is appropriate.12    
Users can also adjust the measures according to their own goals.  Because our goal 
was to identify providers who pose a high risk to Medicare, we set very high 
thresholds.  As a result, our measures may not capture all concerning billing related 
to telehealth services that is occurring in Medicare.  If the goal of the analysis is to 
understand the breadth of a program integrity risk in the program, users may want 
to set lower thresholds for the measures.   
_____________________________________________________________________________________________________________________________ 
12 When identifying outliers, it is important to select an appropriate method based on the data.  For example, one 
option is to identify outliers using percentiles, such as the Tukey method.  The Tukey method identifies outliers as 
values above the 75th percentile plus 1.5 or 3 times the interquartile range.  Another option is to use the standard 
deviation to identify outliers.  For more information about the Tukey method, see J.W. Tukey, Exploratory Data 
Analysis, Addison-Wesley, 1977. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Analysis Steps | 8    
In addition, users may develop additional or related measures to identify program 
integrity risks based on the nature of their program.   
Other Considerations: Incident To Billing  
Under Medicare, 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.   
The measures in this toolkit were designed with incident to billing in mind.  
For example, one measure identifies providers who bill for a high number of 
hours per visit.  A visit is defined as the services provided to one patient in 
one day.  By holding the patient constant, we minimize the effect of incident 
to billing, as a single patient can only receive services from one provider at a 
time.  
 
5. Interpret the results of the analysis 
The results of the analysis can be used to identify program integrity risks associated 
with telehealth.  For example, if a high number of providers exceed the thresholds on 
a measure, that area may be of particular concern in the program and additional 
safeguards, such as pre- or post-payment edits, may be necessary.   
In addition, it may be necessary to conduct additional followup on the individuals 
identified by these measures.  Note that the measures do not confirm that any 
particular provider is engaging in fraudulent or abusive practices.  Any determination 
of fraud or an overpayment would require additional investigation. 
 
 
 
 
 
 
 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Analysis Steps | 9    
PROGRAM INTEGRITY MEASURES 
This section describes each of the seven measures OIG developed that focus on 
different types of billing for telehealth that may indicate fraud, waste, or abuse.  
For each measure, we describe the following:  
  Measure: what the measure is and the type of program integrity risk the 
measure identifies; 
  Analysis: how to calculate the measure; and  
  Threshold: how to identify providers who pose a risk to the program. 
Billing telehealth services at the highest, most expensive level 
for a high proportion of services  
Measure: This measure identifies providers who billed telehealth services at the 
highest, most expensive level every time.  Billing this way may indicate that a provider 
is billing for a higher level of service than was provided to increase their 
reimbursement, a practice sometimes known as upcoding.13   
Analysis: To conduct this analysis, first identify service categories that can be billed at 
different levels depending on the complexity of the patients condition or the 
duration required to diagnose and treat a patient.  In identifying service categories for 
analysis, it may be helpful to select categories with significant differences in 
reimbursement between the highest level and the lowest level.  For example, under 
Medicare, office visits for established patients can be billed using five different 
procedure codes (99211, 99212, 99213, 99214, or 99215) depending on the duration 
of the visit.  The payment rate for the highest level of service (99215) is about eight 
times the rate of the lowest level (99211).   
_____________________________________________________________________________________________________________________________ 
13 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 January 18, 2023. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 10    
 
Office visits for established patients can be billed at different levels based on 
the duration of the visit: 
99211  99212  99213  99214  99215 
Office visit,  Office visit,  Office visit,  Office visit,  Office visit, 
typically   typically   typically   typically   typically  
5 minutes  10 minutes  15 minutes  25 minutes  40 minutes 
Next, for each category of service, determine the percentage of each providers 
services that were billed at the highest level.  When calculating the percentage of 
services for each provider, be sure to account for procedure codes that were billed 
with more than one service unit, if applicable.  For example, in the Medicare data, if a 
procedure code was billed with two service units, we considered that to be two 
services.   
Additionally, to ensure that the results of this analysis identify the providers with the 
most concerning billing, consider limiting this analysis to providers who billed for a 
certain number of services within a service category.  In our analysis of Medicare data, 
we included only providers who had billed Medicare for at least 50 services in any 
given category.   
Threshold: Under Medicare, we considered providers to be high risk on this measure 
if they billed 100 percent of their telehealth services at the highest level in any of the 
service categories selected; most providers rarely, if ever, billed at the highest level.  
This is a conservative threshold.  Users can lower the threshold according to their 
needs and data.  To select a different threshold, review measures of central tendency 
(e.g., mean and median) and the distribution, including outliers in the data.  For 
example, if the purpose of the analysis is to identify potential risks and establish 
safeguards, users may want to set a lower threshold.  However, if the purpose is to 
identify providers for further investigation, users may want to set a high threshold. 
 
 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 11    
Additional Analysis: Identifying Providers Who Billed Beyond the Highest 
Levels of Service 
Additional analysis can provide supplemental information about the providers 
who always billed for telehealth services at the highest, most expensive level.  
In our analysis of Medicare data, we looked at how often these providers billed 
for prolonged services.   
Procedure codes for prolonged services allow providers to increase their 
reimbursement by billing for a service that lasts longer than the highest level.  
For example, CPT code 99354 allows providers to bill for up to an hour 
beyond the highest level.  Further, CPT code 99355 allows providers to bill for 
an additional 30 minutes beyond the first hour. 
                   
              
Billing a high average number of hours of telehealth services 
per visit 
Measure: This measure identifies providers who billed for a high average number of 
hours of telehealth services per visit.  Billing this way may indicate that a provider is 
billing for unnecessary services or for services not rendered.  This is one method that 
providers use to inappropriately maximize their Medicare payments. 
Analysis: There are several steps necessary to calculate a providers average number 
of hours per visit.  When analyzing Medicare claims, we considered a visit to be all 
the telehealth services a provider billed for a 
single beneficiary for one date.   
The first step is to determine the number of  Resource: CMS publishes a list 
minutes it takes to reasonably deliver each  of the median number of 
service.  To do this, one option is to use the  minutes for each procedure 
data that CMS publishes on the median  code.  It can be downloaded 
number of minutes providers spend  from CMSs website.  
delivering each service by procedure code.14  
 
CMS provides this dataset each year with the 
_____________________________________________________________________________________________________________________________ 
14 Some of the procedure codes in our data did not match to CMSs dataset.  When this occurred, we looked at 
the service description to see whether minutes could be assigned.  If a range of minutes was included in the 
description, we conservatively chose the smallest amount.  If we could not establish a median number of minutes 
for a service, we did not include that service in the analysis.   
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 12    
final Physician Fee Schedule, and it can be downloaded from the CMS website.15   
The second step is to calculate the total time spent on the services billed for each 
visit.  To do this, sum all minutes spent on each service provided to a single patient, 
on a single date, by a single provider.  When calculating the time, it is important to 
take the service units into account if a provider billed more than one unit for a given 
procedure code.  
Minutes for Service 1 + Minutes for Service 2 +  =  Total Minutes 
Minutes for Service...  for the Visit 
Third, for each provider, calculate the average minutes across all visits for the year. 
Total Minutes for All Visits / Total Number of  =  Providers Average 
Visits  Number of Minutes 
per Visit 
Fourth, for each provider, convert the average number of minutes to hours by 
dividing it by 60.  
Additionally, consider limiting this analysis to providers who billed for a certain 
number of telehealth visits.  In our analysis of Medicare data, we included only 
providers who had billed for at least 25 or more telehealth visits.  We also excluded 
from our analysis some extra-long services (i.e., those that take more than 100 
minutes and psychological testing and evaluation) to avoid flagging providers who 
were appropriately billing for longer visits.  
Threshold: Under Medicare, we considered a provider to be high risk on this measure 
if they billed for an average of more than 2 hours of telehealth services per visit.  This 
was far higher than the median of 21 minutes of telehealth services per visit for all 
providers who billed Medicare for telehealth services.   
We chose a conservative threshold for our purposes; however, this threshold can be 
changed to fit different needs and data.  Users should review measures of central 
tendency and the distribution, including outliers in their data, to select a threshold 
that meets their needs 
_____________________________________________________________________________________________________________________________ 
15 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.  The download section of this webpage contains a link to download the ZIP folder entitled 
CY 2022 PFS Final Rule Physician Time (ZIP).  This folder contains an Excel spreadsheet with CMSs estimation of 
physician time spent on each service.  Within the Excel spreadsheet, there is a column labeled 
Median_Intra_Service_Time that contains the median number of minutes. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 13    
 
More to Consider: An Impossible Day Analysis 
A common program integrity measure identifies providers who bill for an 
improbable or impossible number of hours in a single day.  For example, a 
provider could not provide, and therefore should not bill for, 25 hours of 
services in a single day.  This is known as an impossible day analysis.   
However, an impossible day analysis is not a good fit for programs that allow 
for incident to billing.  Under incident to billing, services provided by 
clinical staff who are directly supervised by a physician or non-physician 
practitioner may be billed under the supervising practitioners identification 
number.  Consequently, multiple individuals can provide telehealth services 
under a single identification number. 
If your program does not allow for incident to billing, it may be helpful to 
conduct an impossible day analysis to identify concerning telehealth billing.   
 
Billing telehealth services for a high number of days in a year 
Measure: This measure identifies providers who billed for telehealth for a high 
number of days.  Billing this way may indicate that the provider is billing for services 
that were not provided.  
Analysis: To conduct this analysis, for each provider, count the total number of 
unique dates in a 1-year timeframe for which the provider billed at least one 
telehealth service.   
Threshold: Under Medicare, we considered a provider to be high risk on this measure 
if they billed telehealth services for more than 300 days in the year.  This is far higher 
than the median of 26 days of the year for all providers who billed Medicare for 
telehealth services.   
This threshold can be changed to fit different needs and data.  Users should review 
measures of central tendency and the distribution, including outliers in their data, to 
select a threshold that meets their needs.    
Billing telehealth services for a high number of patients  
Measure: This measure identifies providers who bill for a high number of unique 
patients.  Billing this way may indicate that the provider is billing for services that 
were not provided.   
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 14    
Analysis: To conduct this analysis, for each provider, calculate the total number of 
unique patients for whom they had billed at least one telehealth service during a 1-
year timeframe.  
Threshold: Under Medicare, we considered a provider to be high risk on this measure 
if they billed telehealth services for 2,000 or more beneficiaries.  This is far higher than 
the median of 21 beneficiaries for all providers who billed Medicare for telehealth 
services.  
This threshold can be changed to fit different needs and data.  Users should review 
measures of central tendency and the distribution, including outliers in their data, to 
select a threshold that meets their needs.    
Additional Analysis: Identifying Providers Who Billed for Telehealth 
Solely or Primarily for Patients with Whom They Did Not Have an 
Established Relationship 
Users can gain a deeper understanding of the providers who pose a risk by 
conducting additional analysis.  For example, users can identify providers who 
bill solely, or primarily, for patients with whom they have no established 
relationship.  This billing pattern may indicate that these providers are billing 
for telehealth services using stolen or compromised patient identifiers.  In our 
analysis of Medicare data, we considered an established relationship to be a 
prior in-person visit or other service with that same provider (identified by the 
billing providers identification number) within a specified period of time.   
 
 
 
Billing multiple plans or programs for the same telehealth 
service for a high proportion of services  
Measure: This measure identifies providers who bill multiple plans or programs for 
the same telehealth service for a high proportion of their services.  Billing this way 
may indicate that the provider is intentionally submitting duplicate claims to increase 
their payments. 
Analysis: To conduct this analysis, first identify telehealth services that were billed to 
more than one plan or program by matching claims in which information in key fields 
is identical.  In our analysis of Medicare claims, we looked for telehealth services that 
were billed to both a Medicare Advantage plan and Medicare fee-for-service.  To do 
this, we matched information in the following fields: rendering provider, billing 
provider, patient, date of service, and procedure code.  If information in each of these 
fields was identical, we considered both claims to represent the same service.   
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 15    
 
Claim Submitted to Plan 1:  Claim Submitted to Plan 2: 
 
 
Claim  Claim 
  Rendering provider NPI*  Rendering provider NPI 
0123456789  0123456789 
   
 
Billing provider NPI  Billing provider NPI 
  9 87654321  9 87654321 
Patient identification number  Patient identification number 
 
2345234523  2345234523 
   
Date of service  Date of service 
 
01/01/2023  01/01/2023 
   
  Procedure code  Procedure code 
99212  99212 
     
*The National Provider Identifier (NPI) is a unique identification number for health care 
providers. 
To use this measure to identify telehealth services that were inappropriately billed to 
more than one program (e.g., Medicare and Medicaid), additional fields may be 
needed, such as amount paid.  In some circumstances, patients can be enrolled in 
multiple programs.  It is important to understand these circumstances and select the 
fields accordingly.  
Next, determine the percentage of each providers services that were billed to more 
than one plan.   
Additionally, to ensure that the results of this analysis identify the providers with the 
most concerning billing, consider limiting this analysis to providers who billed for a 
certain number of telehealth services.  In our analysis of Medicare data, we included 
only providers who had billed Medicare for at least 50 telehealth services.   
Threshold: Under Medicare, we considered a provider to be high risk on this measure 
if they 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.   
This threshold can be changed to fit different needs and data.  Users should review 
measures of central tendency and the distribution, including outliers in their data, to 
select a threshold that meets their needs.   
 
 
 
 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 16    
Billing for a telehealth service and then ordering medical 
equipment for a high percentage of patients 
Measure: This measure identifies providers who bill for telehealth services and then 
order medical equipment and supplies for a high percentage of their patients.  This 
practice raises concern, as it has been linked to known fraud schemes.  These 
providers may be ordering unnecessary medical equipment and supplies for patients.  
For example, providers may be billing for telehealth services, regardless of whether a 
patient was ever contacted, and ordering medical equipment and supplies as part of a 
kickback scheme with suppliers.  
Analysis: To conduct this analysis, for each provider, calculate the percentage of 
patients for whom they billed a telehealth service and then ordered medical 
equipment and supplies.16  For our analysis of Medicare data, we focused on durable 
medical equipment and components, accessories, and supplies; orthotics and services; 
and prosthetics that were billed within 3 months of the telehealth service.17  
Additionally, to ensure that the results of this analysis identify the providers with the 
most concerning billing, consider limiting this analysis to providers who billed for 
telehealth services for a certain number of beneficiaries.  In our analysis of Medicare 
data, we included only providers who had billed for telehealth services for at least 50 
beneficiaries.   
Threshold: Under Medicare, we considered a provider to be high risk on this measure 
if they billed for a telehealth service and then ordered medical equipment and 
supplies for at least 50 percent of their beneficiaries.  This percentage was far higher 
than the median of 3 percent of beneficiaries for our data.   
This threshold can be changed to fit different needs and data.  Users should review 
measures of central tendency and the distribution, including outliers in their data, to 
select a threshold that meets their needs.    
 
 
_____________________________________________________________________________________________________________________________ 
16 To conduct this analysis, your claims data must include the identification number for the provider who ordered 
the durable medical equipment and supplies.  In Medicare fee-for-service claims, the ordering provider is listed in 
the field for the referring provider.  Under Medicare Advantage, durable medical equipment suppliers are not 
required to include the ordering provider on their claims.  Therefore, we limited our analysis to Medicare fee-for-
service.  
17 Under Medicare, durable medical equipment claims also include immunosuppressive drugs and other supplies 
that may be prescribed on a monthly basis, such as enteral nutrition supplies, end-stage renal disease supplies, or 
surgical dressing.  We did not include these drugs and monthly supplies in our analysis. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 17    
Additional Analysis: Identifying Providers Who Primarily Billed for 
Audio-Only Telehealth Services 
To gain a deeper understanding of the providers who pose a risk, users can 
conduct additional analysis to determine whether these providers billed 
primarily for audio-only services.   
In our analysis of Medicare claims, we identified providers who billed 
primarily for audio-only telehealth services before ordering medical 
equipment and supplies.  This billing pattern may indicate that providers 
are cold calling new beneficiaries to increase orders for medical equipment, 
supplies, and telehealth services. 
To conduct this analysis, determine whether a provider billed for audio-
only services for a high percentage of their telehealth claims.  In Medicare, 
there are six procedure codes99441, 99442, 99443, 98966, 98967, and 
98968used to bill services that are provided exclusively through audio-
only.  We limited our analysis of Medicare claims to these codes.  Although 
Medicare allowed services billed using other procedure codes to be 
provided audio-only, it is not always possible to distinguish which claims 
were for audio-only telehealth services and which were for audio-video 
telehealth services.18 
 
 
18 
Billing for both a telehealth service and a facility fee for most 
visits 
Measure: This measure identifies providers who bill for both a telehealth service and 
a facility fee for most visits.  Under Medicare, a facility feealso known as an 
originating site facility feeis a fee that a health care facility can charge when a 
patient comes to its building to receive telehealth services from a provider who is 
located elsewhere.  The fee reimburses the facility for hosting the patient, e.g., 
providing a room and an interactive device for the telehealth visit.   
_____________________________________________________________________________________________________________________________ 
18 Medicare allowed 86 additional procedure codes to be provided audio-only during our review period; however, 
Medicare data did not distinguish between audio-only and audio-video telehealth for these 86 codes.  CMS now 
requires providers to use a modifier to identify audio-only services for the treatment of mental health conditions.  
See 86 Fed. Reg. 64996 (Nov. 19, 2021). 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 18    
The provider who delivers the telehealth service then bills Medicare separately for the 
service.  Under Medicare, the provider may not bill both the telehealth service and the 
facility fee.19  
 
 
 
Understanding the Facility Fee 
 
A patient goes to a clinic in  The physician provides 
Troy, Illinois (the originating  the telehealth service 
site), to connect with a  using a computer at 
physician in Chicago to  their office in Chicago. 
discuss their symptoms. 
n 
The physician in 
The clinic in Troy bills a 
Chicago bills for the 
facility fee for hosting the 
telehealth service. 
patient. 
Under some plans or programs, such as Medicare, it is inappropriate for the physician 
or practitioner who provides the telehealth service to also bill for the facility fee.  
Billing this way may indicate that the provider is intentionally billing both the 
telehealth service and a facility fee to increase their payments. 
Analysis: To conduct this analysis, first identify telehealth visits that include both a 
telehealth service and a procedure code for an originating site facility fee (Q3014) 
billed by the same provider for the same beneficiary.  Next, determine the percentage 
of each providers visits that included both a telehealth service and a facility fee. 
Additionally, to ensure that the results of this analysis identify the providers with the 
most concerning billing, consider limiting this analysis to providers who billed for a 
certain number of telehealth visits.  In our analysis of Medicare data, we included only 
providers who had billed Medicare for at least 10 telehealth visits.   
_____________________________________________________________________________________________________________________________ 
19 For Medicare requirements, see 42 CFR  414.65(a)(1) and (b)(2).  Given variation in State Medicaid 
requirements for billing the originating site facility fee, it is important to check the billing requirements for each 
State when analyzing Medicaid services delivered via telehealth.  For private health plan carriers, refer to the plans 
specific billing guidelines or policy manual.  For more information about the variation in State Medicaid policies, 
see Medicaid and CHIP Payment and Access Commission, Chapter 2: Telehealth in Medicaid, March 2018.  
Accessed at https://www.macpac.gov/wp-content/uploads/2018/03/Telehealth-in-Medicaid.pdf on November 15, 
2022. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 19    
Threshold: Under Medicare, we considered a provider to be high risk on this measure 
if they billed for both a telehealth service and an originating site facility fee for more 
than 75 percent of their visits; most providers never billed this way.  
This threshold can be changed to fit different needs and data.  Users should review 
measures of central tendency and the distribution, including outliers in their data, to 
select a threshold that meets their needs.    
 
 
 
Additional Analysis: Identifying Additional Characteristics of 
 
Providers Who Pose a Risk to the Program 
 
  There are two additional steps that can be taken to gain a deeper 
  understanding of providers identified as posing a risk to the program.  
 
    Identifying providers who are part of the same medical practice.  
  This can be done by analyzing the providers claims for the 
  organizations that billed Medicare for the telehealth services (i.e., on 
  the basis of the billing providers identification numbers).  Identifying 
  providers who are a part of the same medical practice may indicate 
 
that certain practices encourage such billing among their associated 
 
providers. 
 
 
 
  Identifying providers who appear to be associated with telehealth 
 
companies.  These are companies that employ or contract with 
 
practitioners to provide on-demand telehealth services to 
 
beneficiaries, also referred to as direct-to-consumer telehealth 
 
vendors.  Identifying providers who pose a risk and appear to be 
associated with telehealth companies may indicate a need to monitor 
these companies more closely.  While there is currently no systematic 
way to identify these companies in the Medicare data, a manual 
review can be done on a subset of providers using the name 
associated with the billing providers identification numbers.  Note 
that a single provider may be associated with more than one 
telehealth company. 
 
 
   
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 20    
Notice  
This toolkit was prepared as a technical resource and is not intended to, and does not, 
create any rights, privileges, or benefits, substantive or procedural, enforceable by a party 
against the United States; its agencies or instrumentalities; its officers or employees; or any 
other person.  The toolkit is provided in as-is condition, and OIG and its employees, 
agents, and staff disclaim any express or implied representation, warranty, or guarantee, 
including, but not limited to, the implied warranties of merchantability and fitness for a 
particular purpose.  In particular, no representation is made that the information included 
in the toolkit, or any data the toolkit produces, is error-free. The toolkit should not be used 
as the sole basis to determine whether an individual is inappropriately billing for telehealth 
services.  The toolkit is not intended to be used to determine compliance with any laws, 
regulations, or other guidance.  In no event shall OIG or its employees, agents, or staff be 
liable for any claim, damages, or liability, whether in an action of contract, tort, or 
otherwise, and including direct, indirect, incidental, special, exemplary, or consequential 
damages, however caused, and on any theory of liability, arising in any way out of the use 
of this toolkit, even if advised of the possibility of such damage.  
 
 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Program Integrity Measures | 21    
APPENDIX A
 
Virtual Care Services20, 21  
98966  Telephone assessment and management by nonphysician, 5-10 minutes 
98967  Telephone assessment and management by nonphysician, 11-20 minutes 
98968  Telephone assessment and management by nonphysician, 21-30 minutes 
98970  Online assessment and management by nonphysician, 5-10 minutes 
98971  Online assessment and management by nonphysician, 11-20 minutes 
98972  Online assessment and management by nonphysician, 21 or more minutes 
99091  Collection and interpretation of physiologic data digitally stored and/or transmitted by the patient 
99421  Online digital evaluation and management, 5-10 minutes 
99422  Online digital evaluation and management, 11-20 minutes 
99423  Online digital evaluation and management, 21 or more minutes 
99441  Phone evaluation and management by a physician or other qualified healthcare professional, 5-10 minutes 
99442  Phone evaluation and management by a physician or other qualified healthcare professional, 11-20 minutes 
99443  Phone evaluation and management by a physician or other qualified healthcare professional, 21-30 minutes 
99453  Remote monitoring, setup and patient education 
99454  Remote monitoring, device supply and daily recordings 
99457  Remote monitoring, interactive communication with patient, first 20 minutes 
99458  Remote monitoring, interactive communication with patient, each additional 20 minutes 
99473  Self-measured blood pressure; patient education or training and device calibration 
99474  Self-measured blood pressure and treatment plan 
Payment for virtual care services for 5 minutes or more between a rural health clinic or federally qualified health 
G0071 
center practitioner and a patient 
G2010  Remote evaluation of patient images or video 
G2012  Virtual Check-in 
G2061  Online assessment and management by nonphysician, 5-10 minutes 
G2062  Online assessment and management by nonphysician, 11-20 minutes 
G2063  Online assessment and management by nonphysician, 21 or more minutes 
G2250  Remote assessment of recorded video and/or images submitted by an established patient 
G2251  Brief communication technology-based service, e.g., virtual check-in, 5-10 minutes 
G2252  Brief communication technology-based service, e.g., virtual check-in, 11-20 minutes 
_____________________________________________________________________________________________________________________________ 
20 We refer to these services as virtual care services.  Virtual care services include virtual check-ins, e-visits, remote 
monitoring, and telephone calls with a provider to discuss a patients medical condition.  CMS does not include all 
of these services in its formal definition of telehealth.  
21 This list is based on Medicare fee-for-service payment and coverage policies during the first year of the COVID-
19 pandemic (March 2020 through February 2021).  The services or  procedure codes used to bill virtual care 
services may have changed. 
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Appendix A | 22    
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Miriam Anderson 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 headquarters staff who provided 
support include Michael Novello and Sarah Swisher. 
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
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  Acknowledgments and Contact | 23    
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.  
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks   
OEI-02-20-00723  About OIG | 24