What We Did:
The objective of this audit was to determine whether the Defense Health Agency (DHA) paid for telehealth services in accordance with Federal and DoD guidance.
What We Found:
The DHA improperly paid claims for FY 2020 telehealth services. We obtained a sample of 166 claims for FY 2020 originating site fee claims and 389 additional related claims. We received and reviewed medical records for 138 beneficiaries associated with these claims and determined that the DHA improperly paid 107 originating site fee claims totaling $2,627; we statistically projected that 69 percent of FY 2020 originating site fee payments made by the DHA were unsupported. These improper payments occurred because the DHA did not have controls in place to prevent payment when the claims for originating site and distant site services were performed by the same provider, or when the beneficiary was not present at the originating site.
Additionally, DHA officials improperly paid $1,454 for 15 distant site claims that were not coded as telehealth visits in accordance with TRICARE policy because the DHA did not have controls in place to reject improperly coded claims. The DHA also paid one claim for services inappropriate for telehealth delivery.
As a result of the improperly paid telehealth claims, we projected that the DHA potentially overpaid health care providers for originating site fees by $620,162 from October 2019 through June 2020. These funds could have been used for other critical health care services within the DoD. Additionally, telehealth visits have risen exponentially, and these vulnerabilities could increase the risk of fraud, potentially resulting in a much larger amount of wasted funds. Finally, improperly coded claims may result in under- or over-reporting of telehealth use by TRICARE beneficiaries, which could adversely affect DHA resourcing decisions.
What We Recommend:
We recommend that the DHA Director:
• establish controls that prevent improper payment of originating site fee claims, improperly coded telehealth claims, and claims for services inappropriate for telehealth delivery;
• establish controls that require both patient and provider location for telehealth claims; and
• review FY 2020 telehealth claims payments to recover improperly paid claims.