How changes in Medicaid reimbursements has opened the gates to telehealth fraud

Aug 24, 2021, 6:15 PM | Updated: Jun 19, 2022, 10:02 pm

SALT LAKE CITY — Call it telehealth, telemedicine or even eHealth, online visits with doctors, nurses and other healthcare professionals exploded in popularity during the pandemic.

Unfortunately, the side effect is a new and booming revenue stream for fraudsters.

Telehealth emerged quickly during the pandemic as a necessity for so many Medicaid and Medicare patients that the government and insurers relaxed reimbursement requirements for providers. But experts said that happened without beefing up safeguards, and it opened the floodgates for fraudsters.

Before COVID-19 struck, Medicaid and Medicare only reimbursed providers on many tests and procedures for in-person visits.

Telehealth visits weren’t acceptable back then, but they are now, and the bad guys have caught on fast.

“It created a huge opportunity for fraudulent activity,” said Haywood Talcove, the CEO of LexisNexis Risk Solution’s government division.

Talcove’s group has been digging into Medicaid billing records, and in numbers shared with the KSL Investigators, they showed $4.5 billion in taxpayer money has already been pocketed in fraudulent telehealth schemes.

Talcove believes that number will climb much higher.

And officials with the Utah Department of Health confirmed it is an issue in Utah, telling the KSL Investigators in a statement, “We follow the national trends.”

“You saw just a huge uptick in the use of stolen information to perpetrate fraudulent activity by providing services that were never provided,” said Talcove.

He explained the crooks use stolen identities of both providers and patients, living and deceased, to bill Medicaid for countless hours of telehealth visits that happen only on bogus paperwork.

Some schemes are difficult to detect, others are much easier.

“That person’s working 23 hours a day, doing eight appointments an hour and not even taking a break! What a dedicated provider!” he said sardonically.

Besides their identities being used, patients could face denials of benefits down the road.

“You could find yourself in ‘Medicaid prison’ because it’s going to appear that you’re getting service inappropriately and not following the rules,” Talcove said. “You’re on Medicaid. You need health care services, and you can’t get them, right? Because someone stole your identity and used it inappropriately.”

The solution?

Talcove said Medicaid agencies should consult with businesses in the private sector and see how they are detecting fraud.

“The fraud patterns are very familiar to places like Amazon, Target, the credit card companies – there’s no surprise there,” he said.

He also pushed those agencies to enhance their data and analytic systems, so they are working virtually full-time.

“It doesn’t do any good to let a provider bill for three months and realize it was fraudulent and you just paid out $5 million,” Talcove said, who also recommended Medicaid agencies adopt identity validation from a third party, so they are not relying solely on information given by providers or patients that could be fraudulent.

For its part, UDOH told KSL, “We are working with Centers for Medicare and Medicare Services’ Center for Program Integrity, the U.S. Department of Health and Human Services’ Office of Inspector General and other states’ Program Integrity Units to ensure we stay on top of any emerging fraud trends.”

As for consumers, another telehealth scam has fraudulent providers calling people to convince them they’ve got COVID-19 and should visit a medical professional online.

They’ll ask for personal information that will end up in the hands of crooks.

That is a call you should hang up on.

KSL 5 TV Live

Top Stories

KSL Investigates

Matt Gephardt

Get Gephardt: How do you know if your donation really gets to those who need it?

Fundraising runs rampant on social media, but how do you know if your donation really gets to those who need it?
2 days ago
After a contractor got paid, customers say he stopped responding and walked off the job. (KSL TV)...
Matt Gephardt and Cindy St. Clair

Felony charges for contractor accused of ripping off several Utahns

After a contractor got paid, customers say he stopped responding and walked off the job. A Get Gephardt investigation found this particular contractor has walked off so many jobs it could land him behind bars.
3 days ago
Christopher Browning in court....
Daniella Rivera & Keira Farrimond

Police were warned rapist could reoffend 24 years ago. Now he’s charged again.

A convicted rapist paroled in December faced a Utah judge today on 10 new felony charges including aggravated sexual assault and kidnapping.
4 days ago
Matt Gephardt and Cindy St. Clair

After new homes flood, residents question if builder or Mother Nature is to blame

Several new homes in a Lehi community flooded during rainstorms earlier this month. When they say the home builder told them they weren’t responsible, they decided to Get Gephardt to investigate.
5 days ago
Matt Gephardt

Get Gephardt: The ‘most used’ photos to catfish victims in romance scams

KSL Investigator Matt Gephardt shows us some of the most widely used photos in romance scams and how we can protect ourselves.
6 days ago
Americans are using their credit cards more often as the economy opens....
Matt Gephardt

Gephardt Busts Inflation: The key to saving money on your credit card bills

More Utahns are carrying debt, but the thing is – many of those folks have no idea how much interest they are paying on their debt.
10 days ago

Sponsored Articles

vintage photo of lighting showroom featuring chandeliers, lamps, wall lights and mirrors...
Lighting Design

History of Lighting Design | Over 25 Years of Providing Utah With the Latest Trends and Styles

Read about the history of Lighting Design, a family-owned and operated business that paved the way for the lighting industry in Utah.
Fiber Optical cables connected to an optic ports and Network cables connected to ethernet ports...
Brian Huston, CE and Anthony Perkins, BICSI

Why Every Business Needs a Structured Cabling System

A structured cabling system benefits businesses by giving you faster processing speeds and making your network more efficient and reliable.
notebook with password notes highlighted...
PC Laptops

How to Create Strong Passwords You Can Actually Remember

Learn how you can create strong passwords that are actually easy to remember! In a short time you can create new ones in seconds.
house with for rent sign posted...
Chase Harrington, president and COO of Entrata

Top 5 Reasons You May Want to Consider Apartment Life Over Owning a Home

There are many benefits of renting that can be overshadowed by the allure of buying a home. Here are five reasons why renting might be right for you.
Festive kitchen in Christmas decorations. Christmas dining room....
Lighting Design

6 Holiday Decor Trends to Try in 2022

We've rounded out the top 6 holiday decor trends for 2022 so you can be ahead of the game before you start shopping. 
Happy diverse college or university students are having fun on their graduation day...
BYU MBA at the Marriott School of Business

How to Choose What MBA Program is Right for You: Take this Quiz Before You Apply!

Wondering what MBA program is right for you? Take this quiz before you apply to see if it will help you meet your goals.
How changes in Medicaid reimbursements has opened the gates to telehealth fraud