Leverage payment integrity solutions to ensure proper billing of tele-health services
- Jun 25, 2025
- 3 min read
Don’t be surprised if the U.S. Department of Health and Human Services extends the COVID-19 public health emergency in mid-July, givenealth emergency in mid-July, based on what government officials have said.
If it ends, however, the news will be cushioned by a five-month extension of telehealth flexibilities created during the coronavirus pandemic. Congress granted that extension as part of the sweeping omnibus spending bill approved in March.
Those accommodations will provide patient-centric benefits by expanding access to providers, allowing adults aged 65 or older, including senior living residents, to use Medicare coverage for telehealth visits, regardless of location. Under those flexibilities, all Medicare-enrolled providers can bill for telehealth services delivered from the patient’s home as well as from medical facilities. The bill will also postpone the requirement that older adults who seek virtual mental healthcare have an in-person follow-up appointment within six months, taking the strain off medical staff and caregivers coordinating those visits.
Although the benefits to patients are clear, greater tele-health flexibilities create more room for healthcare billing fraud, waste, and abuse, or FWA, through potential coding and payment aberrations affecting payers and providers alike. Pre-pandemic, claim-related FWA was a top issue for health plans aiming to evolve both care quality and consumer expectations for the experience. The pandemic, however, created the need for overhauled payment integrity solutions, including complete process re-engineering and AI, automation, and analytics enablement.
As payers and providers grapple with compounding operational challenges across the board due to the COVID-19 pandemic, their relationship is further strained by gaps in knowledge of ever-changing Centers for Medicare & Medicaid Services guidelines and documentation requirements for smooth claims processing. Those learning gaps often intensify billing and coding errors between providers and payers.
To prevent further strain on back-office staff, providers should consider partnering with trusted third parties to ensure proper billing and coding. Payment integrity solution providers are key to improving information accuracy between providers and payers, ensuring there aren’t post-pay audit issues associated with par/non-par providers in relation to new regulations around billing processes.
In April, the Department of Health and Human Services Office of Inspector General, along with its law enforcement partners, participated in a sweeping, coordinated law enforcement action to combat COVID-19-related healthcare fraud.
Twenty-one defendants in nine federal districts across the United States were charged for their alleged participation in various healthcare fraud schemes that exploited the COVID-19 pandemic and resulted in more than $149 million in false billings. Defendants included telemedicine companies, physicians, marketers, and medical business owners.
With the growing prevalence of tele-health came increasing risks of coding e-visits or virtual check-in claims as higher-level tele-health visits, as well as up-coding evaluation and management services to a higher level than actually rendered. According to research by Medical Billing Advocates of America, 80% of medical bills contain errors. Although the expansion of reimbursable telehealth services may increase such errors, the need to educate providers to change their billing patterns becomes increasingly important. To combat these billing errors, highly trained coding resources are needed to ensure compliance standards are met while still achieving cost and operational optimization, with the implementation of new tools such as analytics, AI, and automation.
As expert problem-solvers, payment integrity solution providers can leverage their exposure to and understanding of the nuances of the COVID-19 telehealth impact to assist payers and providers in navigating changing regulations and documentation requirements, and in understanding how they can affect business from an end-to-end perspective. With the right payment-integrity approach and attention to detail, providers will be able to focus on the quality of care while thriving in today’s environment.
Comments