Telemedicine Fraud Scams That Might Surprise You

One of the questions our Special Investigations Unit (SIU) has received from business partners relates to the types of telemedicine fraud we saw during the pandemic. 

The SIU community and ICW Group were very wary of the fraud anticipated from the explosion of virtual or telemedicine during COVID-19. Candidly, those concerns remain post-COVID as the public’s acceptance and use of telemedicine continues to increase. What we observed was interesting in that the crooks simply recycled schemes and scams. Rather than finding new ways to commit fraud within the workers’ compensation system, we saw, and continue to see, a slight pivot on age-old scams. 

Types of telemedicine scams

  • Billing for services not rendered.
  • Upcoding, which is when a less expensive service is billed as if a more expensive service was performed.
  • Unbundling is where separate procedures are billed individually rather than collectively to inflate the charges.
  • DME, or durable medical equipment fraud. Billing for high-end items when dispensing lower-priced items, billing for materials not dispensed at all, and billing and dispensing excessive and unnecessary quantities of materials and equipment.
  • Misrepresenting the services provided. For example, E&M (Evaluation and Management) codes and actions require audio and video interactions with a patient. If the service provided is only telephonic, it does not qualify.
  • Unethical practitioners may engage in kickback arrangements or referral schemes where they receive payment for patient referrals.

Telemedicine can be a great service to injured workers, and ICW Group offers telemedicine services through a trusted partner. If employees use another telemedicine service not associated with ICW Group, rest assured that our fraud-fighting team is paying attention.

Our ability to drill deeply into our data, our relationships with law enforcement and the greater anti-fraud community, and our decades of hands-on experience allow us to remain at the forefront of identifying fraud in this area.

Brian Biggs
Brian Biggs
Brian serves as the Manager of ICW Group’s SIU team. He has been in the industry since 1997 in a variety of roles including Claim Professional, SIU Investigator and SIU Director. Brian has previously been elected President of multiple anti-fraud industry trade organizations and is joining the Board of the Anti-Fraud Alliance in early 2024. He has attained more than fifteen professional designations including the CPCU, Certified Insurance Fraud Investigator and Associate in Risk Management. Brian is frequently asked to present at conferences and industry meetings and revels at these opportunities. Brian welcomes the opportunity to speak with anyone, anywhere, anytime about insurance fraud (and all manner of BBQ).

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