What are the Medicare Telemedicine Rules?

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At The Criminal Defense Firm, we are increasingly being contacted by health care providers who are facing federal investigations of their telemedicine and telehealth practices. From San Francisco to Miami and from Colorado to New York, health care providers across the country are facing civil and often criminal accusations for alleged violations of Medicare’s rules governing the practice of telemedicine.

Medicare’s Basic Rules for Telemedicine

The Medicare Fee-For-Service Program provides reimbursements for telemedicine services only under certain, limited circumstances. Among the requirements for reimbursement are the following:

  • The eligible Medicare beneficiary must participate from an accepted Originating Site. An “Originating Site” is the location where the patient is present at the time of service.
  • The Originating Site must be in a Health Professional Shortage Area (HPSA), or outside of any Metropolitan Statistical Area (MSA).
  • The services provided must be accepted reimbursable services.

As a result, contrary to popular belief, telemedicine is not allowed to be conducted at the patient’s home. Rather, all sessions must take place inside a medical facility, such as a doctor’s office, hospital, or regional clinic. In addition, the interaction between patient and doctor has to be face-to-face, so telemedicine sessions must be conducted via a live video conference with the patient being physically present at the Originating Site.

Who Is Eligible to Provide Telemedicine Services?

Subject to applicable law, physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, registered dietitians, registered nutrition professionals, and, to some extent, clinical psychologists and clinical social workers are all permitted to furnish and bill for telehealth and telemedicine services.

Where Must the Patient Be During the Consultation?

As noted above, it is not permissible for patients to receive telemedicine consultations and treatment at their homes. Instead, Medicare requires that the patient be present at an “Originating Site.” Permissible Originating Sites include:

  • Community Mental Health Centers (CMHC)
  • Critical Access Hospitals (CAH)
  • Federally Qualified Health Centers
  • Hospitals
  • Physicians Offices
  • Rural Health Clinics
  • Skilled Nursing Facilities (SNF)

Common Mistakes Leading to Telemedicine Investigations

Unfortunately, many telemedicine providers become the subjects of federal investigations after making common, avoidable mistakes. Based on our experience, the five most common mistakes that lead to Medicare fraud investigations involving telemedicine are:

  1. Using unapproved codes (not all traditional CPT codes apply to telemedicine).
  2. Receiving or paying illegal kickbacks to physicians, pharmacies, marketers and other third parties.
  3. Violating of Medicare, Tricare, and Department of Labor rules.
  4. Treating patients from states where a physician is not licensed.
  5. Unauthorized prescription practice.

About The Criminal Defense Firm

Our Attorneys

The Criminal Defense Firm is a team of health care fraud defense lawyers with a successful track record defending cases that result in no civil or criminal liability for our clients.

Our Telemedicine Experience

We have represented clients in telehealth and telemedicine cases across the country. Few other law firms can match our depth of experience in this complex area of the law. Our attorneys have handled numerous cases involving:

  • Telemedicine and Prescription Practice
  • Telemedicine and Compound Pharmacy Referrals
  • Telemedicine and Anti-Kickback Issues
  • Telemedicine and Stark Law Questions
  • Telemedicine Defense (Department of Justice)
  • Telemedicine Defense (FBI, OIG Investigations)
  • Telemedicine Defense (U.S. Attorney’s Office)
  • Telemedicine Defense (HEAT Task Force, Florida)
  • Telemedicine Defense (Medicare Fraud Strike Force)

Speak with an Attorney about Your Telemedicine Practice Today

If you would like to speak with a former federal health care prosecutor and experienced health care defense attorney about your telemedicine practice, contact The Criminal Defense Firm today. Call 866-603-4540 or tell us about your situation online to schedule your free, confidential consultation now.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results do not guarantee similar future outcomes. The Criminal Defense Firm is a Texas firm with headquarters in Dallas.
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