Durable Medical Equipment (DME) fraud has long been a focus of DOJ and HHS-OIG enforcement efforts both nationally and in Nashville. A more recent priority in combatting Medicare fraud has been perceived abuses in the field of telehealth, or telemedicine. These two areas are at the center of one of the first criminal healthcare fraud cases of 2020.

On January 14, 2020, the United States Attorney’s Office for the Middle District of Tennessee announced that it has charged James L. Crabb, M.D., of Loretto, Tennessee, in a $7 million healthcare fraud conspiracy. Crabb was a consulting medical provider to a Florida-based telehealth company. He received unsigned DME orders and prescriptions from the company for Medicare beneficiaries.  He allegedly signed the orders and prescriptions absent any pre-existing doctor-patient relationship and regardless of medical necessity.

The Crabb case is part of a trend of increasing scrutiny by federal and state agencies on telehealth arrangements. This trend is likely to continue as more healthcare providers employ modern telecommunications in their practices.  According to the National Review Online Medicare payments for telehealth increased by 28% in 2016 alone. That year, Medicare paid almost $30 million on nearly 500,000 telehealth claims.  Those numbers continue to rise.

The Crabb case is part of a trend of increasing scrutiny by federal and state agencies on telehealth arrangements. This trend is likely to continue as more healthcare providers employ modern telecommunications in their practices.

Healthcare companies and individual physicians need to be aware of applicable requirements for providing telehealth services. The Information in the Crabb case alleges that the face-to-face visit required for the prescription of DME could occur via telehealth

provided certain requirements were met, including (a) that the beneficiary was located in a rural or health professional shortage area; (b) that the services were delivered via an interactive telecommunications system, not simply by telephone or email; (c) that the beneficiary was at a practitioner’s office or specified medical facility – not in the beneficiary’s own home – during the telehealth medical consultation; (d) that the ordering provider be a physician or other qualified health professional; and (e) that the medical examination was under the provider’s control

More detail about Medicare billing guidance for telehealth services can be found in the Medicare Claims Processing Manual, Chapter 12. Telehealth requirements can vary significantly for non-Medicare payors.

We will continue to monitor the Crabb matter and the evolving case law involving telehealth. Subscribe to the SRVH blog for further updates and contact the lawyers in our Government Compliance & Investigations or Healthcare groups with any questions or concerns.

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