Health Care/Joan Retsinas

COVID Capitalism Segues into Fraud

Why let a pandemic go to waste? COVID Capitalism 101 instructs: Seek out the opportunities amidst the despair.

COVID left people who depended upon mental health counseling, as well as pharmacological drugs, in a bind. Suddenly, the crucial in-person sessions ended, as the nation hunkered down. And the isolation deepened many patients’ symptoms.

At the same time, many other Americans, forced not just into isolation but into near-penury by COVID-driven unemployment, felt sad, depressed, discouraged. They might have benefited from counseling, but they, too, met the closed doors of the pandemic.

“Telehealth” emerged as a deus ex machina. A patient could hook up, via Zoom or maybe a telephone, to a therapist. No need to travel, to sit, masked, in a waiting room, to talk, masked, to a masked therapist. And the patient at home might feel more relaxed, more comfortable sharing symptoms. Telehealth offered benefits.

Happily, insurers reimbursed the sessions, as insurers would have reimbursed in-person sessions. (Before the pandemic, there were stringent restrictions on billing for telehealth.)

Telehealth for behavioral health surged during the pandemic. While the number of in-person visits plummeted, the number of telehealth visits during the pandemic was higher than the number before, according to a report from the Rand Corporation, based on 5,142,577 adults with private insurance. The increase was especially strong for anxiety disorders - again, not surprisingly. Analysis of data from several health plans, using diagnostic codes, shows that telehealth visits rose from just 0.5%% in 2019 to nearly 40% in 2022.

Telehealth in general — not solely for behavioral health — emerged as a profitable line. A 2021 McKinsey report, “A quarter-trillion-dollar post-COVID-19 reality?”, pegged overall telehealth billing at 17% for all office/outpatient visits. The federal government has allowed the extension of telehealth through Dec. 31, 2024, for specific services, including hospice, physical and occupational therapy, and behavioral therapy.

But with the end of the COVID-driven lockdown, physicians’ offices are once again opening. For many physicians, the new modus operandi is the old one: an office visit. In the future, AI technology, armed with test results and coupled with Zoom, may replace the office visit, but not yet.

Mental health counseling, though, remains a telehealth possibility. While some patients may benefit more from an office visit, others do better talking to a therapist from home.

But if telehealth is easier for the clinician and the patient, so too it is easier for fraud.

Here are some of the opportunities:)

• A therapist can bill for individual services, when “seeing” a group, including a group that includes family members. Presto: a clinician can bill for five individual sessions, instead of one group session.

• Multiple hours on multiple days. No therapist works 24 hours, but a review of billing data showed that some therapists purported to do just that.

• Upcoding that adds to a psychotherapy session an “evaluation and management” code, which generally denotes a medical service. A clinician would need to include a medical office visit in addition to a counseling session.

One Medicare investigation found that a therapist billed an average of four hours per visit for 37 different visits. That clinician and six others who overbilled during the first year of the pandemic worked for the same Florida chain of mental health and substance abuse offices.

Patients, moreover, rarely scrutinize the bills if an insurer picks up the tab.

The White Collar Crime Committee Newsletter, Winter/Spring 2021, published by the ABA Criminal Justice Section’s White Collar Crime Committee, sums up the correlation: “Fraud Emerges as Telehealth Surges.”

In response, the Department of Justice has begun investigating the “fraud and abuse” in telehealth. Expect the Department, along with insurers, to rein in virtual behavioral health. The challenge: keeping telehealth a genuine option, while rooting out the fraud. It is a battle between the insurers — Medicare, Medicaid and private insurers — and fraudsters. Let’s hope patients do not ultimately lose this valuable chance for therapy.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.

From The Progressive Populist, June 1, 2023

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