Telehealth and Trauma – Following the Rules to a “T”

We all know now that the federal telehealth waivers were allowed to expire while Congress continues the stalemate over the budget. And in the Centers for Medicare & Medicaid Services (CMS) bulletin released at the start of the shutdown, the agency suggested that providers could offer Advance Beneficiary Notices (ABNs) to Medicare patients who are willing to pay to proceed with a telehealth visit.

The providers could get the patient’s verbal agreement, email or mail the ABN for the patient to sign and send back, and then the provider could hold the claim until the new budget passes – and hope that telehealth coverage is retroactive to Oct. 1. If so, they could submit the claim and get paid by Medicare, and if the coverage is not extended, they could bill the patient directly.

But here is the problem with that. The Medicare Manual has two requirements that may be hard to meet. First is that the ABN must be “provided far enough in advance of delivering potentially non-covered items or services to allow sufficient time for the beneficiary to consider all available options,” and second is that the ABN must be “explained in its entirety, and all of the beneficiary’s related questions are answered timely, accurately, and completely to the best of the notifier’s ability.”

It would not be enough to say to a patient on the phone or other technology that the visit may not be covered, ask if they want to proceed and pay for it themselves, and then send the form. When they get the bill from the doctor for the visit, the patient could claim they did not have adequate time, and agreed to proceed without even having the form to review. And I suggest that both those arguments would be enough for their appeal to be successful and free the patient of liability. Now, the telehealth provider could have staff call the patient in advance of the visit to explain the ABN, provide options, and answer questions; that would work with scheduled visits, but might be difficult to operationalize with urgent visits. 

Moving on to another topic, two weeks ago the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report on billing of trauma activation by hospitals. It is interesting that this issue was added to the Work Plan in November 2022, the charts that were audited were from January 2020 to June 2022, the OIG paid an outside auditor to analyze the cases, and there was no report until September 2025. Three years to audit 125 claims; where can I sign up to be an OIG auditor?

So, as often happens, the OIG reported a very high error rate, finding that 77 percent of claims were improper and estimating that during those 2½ years, CMS overpaid $2.4 billion in unallowed charges. And if I extrapolate that number, it means that since June 2022, another $3.3 billion in improper payments has been paid out while the OIG and its contractor took their time producing his report.

But the real fun was reading the response from CMS. CMS totally discounted the OIG’s findings, noting that the OIG did not use the right criteria to determine if trauma activation was billed correctly, but not noting which criteria they used were wrong or what criteria they should have used.

The OIG also pointed out that CMS’s most recent education on this topic was from 2007, and recommended CMS provide more frequent education, to which CMS noted that they will assess the need for additional education. I suspect something has changed in 18 years, and if not, a refresher after that long certainly cannot hurt.

But the message here is that if you are a trauma center, review your coding of trauma activation and be sure it follows the rules, whatever they may be.