Telehealth at the Crossroads
Protecting a Lifeline for Chronic Disease Patients While Closing the Door on Fraud
Investigative Policy Analysis · IPCSG Research Series · February 21, 2026
Health Policy & Program Integrity
Telehealth is not a luxury for the chronically ill — for cancer patients, dialysis patients, and those managing complex multi-drug regimens, it is a clinically validated, cost-effective necessity. The evidence shows that well-designed telehealth does not increase downstream hospitalizations or emergency visits. The fraud problem is real but traceable to a specific, identifiable set of bad actors — fly-by-night telehealth mills, fraudulent DME schemes, and unscrupulous genetic testing companies — not to the established patient-physician relationships that responsible telehealth protects. The policy solution is not restriction, but precision: robust pre-payment screening, mandatory provider identity verification, strong clinical documentation requirements, AI-assisted anomaly detection, and a tiered framework that extends full flexibility to qualified providers with documented patient relationships while applying heightened scrutiny to high-risk billing categories. Congress has the tools. The legislation exists. The question is whether political will can be sustained past the next funding deadline.
01 The Case for Telehealth in Chronic and Oncologic Care
Before any discussion of fraud controls, the clinical record must be stated plainly. For patients managing cancer, chronic kidney disease, heart failure, or advanced prostate disease requiring complex hormonal and radiopharmaceutical regimens, telehealth is not a convenience — it is a medically rational, evidence-backed delivery model.
What the Clinical Literature Shows
A landmark 2025 study published in the Journal of Medical Internet Research examined telemedicine use across five chronic disease specialties — including hemato-oncology — at a major academic medical center and found that increased telehealth use was not associated with higher emergency department referrals or hospitalizations compared to in-person visits. The researchers concluded that telemedicine can be safely tailored to individual patient-physician relationships across complex chronic conditions.
A comprehensive 2025 Johns Hopkins study published in JMIR Cancer analyzed telehealth patterns across the cancer care continuum and found that virtual visits remained a widely used care delivery mode, with utilization patterns closely tied to disease phase and patient functional status. Critically, telehealth's association with key healthcare outcomes held even among older patients — a population frequently assumed to be poor candidates for virtual care.
A 2025 UCLA/Columbia study published in the Journal of Telemedicine and Telecare examined 30-day downstream utilization following telehealth versus in-person oncology visits and found no significant increase in ED visits or hospitalizations attributable to virtual care. The researchers noted that telehealth is particularly valuable for patients with compromised immune status for whom infectious exposure in clinic waiting rooms represents a genuine clinical risk.
The Lancet Digital Health's comprehensive 2023 scoping review of reviews on digital health and telehealth in oncology found that virtual care delivery reduces time burdens of cancer treatment, extends access to evidence-based interventions for surveillance and supportive care, and is an increasingly viable option for older adults. The review notably flagged the near-total absence of studies focused specifically on patients aged 65 and older — the very Medicare population most affected — as a critical research gap demanding urgent attention.
For the specific population of seniors in active cancer treatment, the practical calculus is straightforward. A prostate cancer patient on Xtandi monitoring PSA levels every eight weeks does not need to drive to an oncology center for a blood work review and prescription renewal. A patient receiving oral targeted therapy who reports manageable fatigue and controlled PSA does not need a two-hour round trip that could be safely replaced by a 20-minute video consultation. A patient considering Pluvicto — or enrollment in an Actinium-225 clinical trial — benefits enormously from telehealth-enabled access to distant subspecialty expertise that would otherwise require significant travel.
Key Clinical Finding — Oncology
Research across multiple academic medical centers consistently shows that telehealth in oncology does not increase emergency utilization when used in established patient-physician relationships with appropriate documentation. The clinical risk of inappropriate virtual care is not inherent to the modality — it is a function of provider quality and documentation discipline.
02 The Fraud Problem: Specific, Not Generic
The fraud that has plagued Medicare telehealth billing is real and massive. In July 2025, the DOJ's largest healthcare fraud takedown in history — "Operation Gold Rush" — charged 324 defendants with $14.6 billion in false claims, with 49 defendants charged in connection with over $1.17 billion in telehealth and genetic testing fraud alone. In 2023, a separate DOJ action charged defendants in a scheme billing more than $1.5 billion for medically unnecessary DME and prescription drugs via fraudulent telehealth platforms.
But the pattern of telehealth fraud is instructive: it is not primarily occurring in oncology practices, nephrology clinics, or cardiology follow-up visits. The fraud clusters in specific, identifiable categories:
- Telehealth mills: Companies with no established patient relationships that generate thousands of prescriptions or DME orders from physicians who never meet the patients, operating as high-volume billing engines with no clinical substance.
- Genetic testing fraud: Entities that approach Medicare beneficiaries at pharmacies, health fairs, or via cold calls offering "free" cancer screening swabs, bill Medicare thousands of dollars per test, and pay kickbacks to physicians whose only role is signing the order.
- DME referral schemes: Telehealth platforms functioning purely as conduits to generate orders for high-cost durable medical equipment — back braces, power wheelchairs, CPAP devices — shipped without genuine clinical evaluation.
- Controlled substance mills: Platforms using relaxed DEA telehealth prescribing rules to generate high-volume opioid and stimulant prescriptions — the dominant target of the November 2025 conviction involving a $100 million Adderall scheme.
In every category above, the defining characteristic is the absence of an established, documented patient-physician relationship. The fraud is almost always new-patient, unsolicited, and volume-driven. It is categorically distinct from a medical oncologist conducting a follow-up visit with a patient he has treated for five years.
Policy Insight
Fraud-prevention policy that treats a cancer patient's quarterly telehealth check-in with his oncologist identically to a telehealth mill cold-calling seniors for genetic swabs is not precision policy — it is blunt-force restriction that harms patients without meaningfully deterring fraud. The existing patient relationship is the most powerful single fraud-prevention variable available.
03 The Legislative Battlefield: Where Congress Stands
Medicare telehealth policy has been governed since 2020 by a series of COVID-era emergency waivers. Most recently, the Consolidated Appropriations Act of 2026, signed February 3, 2026, extended most Medicare telehealth flexibilities through December 31, 2027. But this is the fourth major extension. Without permanent legislation, the cycle repeats in January 2028 — and as a Brown University analysis of the October 2025 government shutdown demonstrated, even brief lapses cause 24% drops in telehealth utilization nationally, with states like Florida, New York, and Louisiana seeing drops of 40% or more.
The 119th Congress has four substantive telehealth bills before it:
| Legislation | Key Provisions Relevant to Chronic Care and Fraud Controls |
|---|---|
| CONNECT for Health Act of 2025 S.1261 / H.R. 4206 Bipartisan |
Permanently removes geographic and originating site restrictions. Expands eligible provider types. Adds program integrity guardrails: outlier billing review, enhanced oversight, data transparency requirements, and fraud/abuse clarifications. Backed by AMA, ATA, and Alliance for Connected Care. |
| Telehealth Coverage Act of 2025 H.R. 2263 |
Full permanence for home-based telehealth and audio-only services. Permanently includes physical/occupational therapists. Makes Hospital-at-Home program permanent. Adds guardrails for compliance monitoring. |
| Telehealth Modernization Act of 2025 S.2709 / H.R.5081 Bipartisan |
Bridge bill extending flexibilities through September 2027. Adds targeted fraud-prevention oversight for DME and high-risk lab tests — directly addressing the primary fraud vectors. Authorizes in-home cardiac and pulmonary rehab via audio-video. |
| Preventing Medicare Telefraud Act H.R. (2025) |
Standalone fraud-prevention bill. Requires providers to use their own NPI when billing for telehealth services — eliminating signature mills. Authorizes CMS to audit outlier DME/lab-test orderers. Implements OIG recommendations on provider relationship transparency. Corrects NPI deactivation authority for convicted fraudsters. |
The policy architecture needed to allow appropriate telehealth while controlling fraud is not particularly complex in principle. What follows is a framework drawn from OIG recommendations, GAO findings, the CONNECT Act's integrity provisions, the Preventing Medicare Telefraud Act, academic health policy research, and the practical experience of major academic medical centers that have operated high-volume telehealth programs since 2020.
The single most powerful fraud-prevention mechanism is a documented, prior clinical relationship. Policy should codify a tiered framework:
Established Relationships (within prior 12 months)
Streamlined documentation, no additional prior authorization for visit types previously delivered in person. Protects cancer follow-up, chronic disease management, and ongoing specialist relationships — where the clinical evidence confirms safety.
New Patient Encounters in High-Risk Categories
New-patient telehealth visits for DME orders, high-cost lab tests, or controlled substance prescriptions require additional documentation, use of the ordering provider's own NPI, and are subject to pre-payment AI screening. This is where the fraud occurs.
Telehealth-Only With No In-Person Baseline + Immediate High-Cost Orders
Genetic panels, power wheelchairs, specific DME categories ordered through telehealth with no established relationship require in-person validation or enhanced pre-authorization regardless of any claimed relationship.
- Real-time NPI cross-matching: Automated verification at claim submission that the ordering provider NPI matches the provider who conducted the documented telehealth encounter.
- NPI deactivation authority: Convicted fraudsters' NPIs should be deactivated automatically upon conviction, and their enrollment in related entities flagged for review. Current law perversely requires the fraudster to self-report.
- Relationship transparency requirements: CMS should collect and publish data on provider relationships with telehealth platforms and Medicare Advantage organizations, creating accountability for referral patterns suggesting kickback arrangements.
CMS's WISeR (Wasteful and Inappropriate Service Reduction) model pilot represents the first serious federal deployment of pre-payment AI for Medicare claims screening, currently active in six states. The AMA's concern — that the model could delay care — is legitimate and must be addressed in the model's design.
- Anomaly targeting, not routine gatekeeping: AI pre-payment review should be triggered by statistical outliers — providers ordering DME at 10x the specialty average, genetic testing volumes inconsistent with any credible patient panel — not applied as a blanket prior authorization for routine telehealth visits.
- Clinical guideline alignment: Any AI-flagged service should be evaluated against physician-developed clinical guidelines, not purely actuarial cost metrics.
- Rapid appeals with 72-hour turnaround: For flagged claims from established practices with clean billing histories, an expedited review pathway should operate within 72 hours to prevent disruption to ongoing care.
- Transparent feedback to providers: Legitimate providers whose billing is flagged should receive specific, actionable explanations — not opaque denials.
- Structured encounter documentation: Telehealth encounters in high-risk categories should include structured documentation elements sufficient to demonstrate a genuine clinical interaction occurred — vital signs reported by patient, current medication list review, specific clinical questions addressed.
- EHR linkage: Telehealth claims should be linkable to EHR encounter notes through MAC audit processes. Absence of a corroborating EHR note for a billed telehealth visit should be a pre-payment audit trigger.
- Patient confirmation systems: For high-value orders generated through new-patient telehealth encounters, a beneficiary confirmation — analogous to credit card fraud alerts — should verify participation before payment is released.
- Quarterly public data release: CMS should publish quarterly telehealth claims summaries by billing code, provider type, and state — enabling ongoing independent audit by academic researchers, watchdog organizations, and investigative journalists, as demonstrated by the February 2026 HHS Medicaid data release.
- False Claims Act Working Group integration: The DOJ-HHS FCA Working Group launched July 2025 should specifically prioritize telehealth claims analytics as an early-identification tool.
- Whistleblower optimization: The qui tam mechanism has generated billions in telehealth fraud recoveries. CMS and DOJ should streamline FCA Working Group coordination to reduce investigation timelines.
Established Relationship Tiers
Full flexibility for documented ongoing relationships; enhanced scrutiny for new-patient high-cost orders.
NPI Identity Integrity
Mandatory own-NPI billing; automatic deactivation for convicted fraudsters; relationship transparency.
AI Anomaly Screening
Targeted pre-payment review for statistical outliers; clinical guideline alignment; 72-hr appeals.
Documentation Standards
Structured encounter records; EHR linkage requirements; patient confirmation for high-value new-patient orders.
Transparency & Monitoring
Quarterly public claims data; FCA Working Group integration; optimized whistleblower pathways.
- Pass the CONNECT for Health Act with mandatory integrity guardrails. Permanently resolve telehealth access uncertainty — the cycle of 90-day extensions is itself a patient safety problem.
- Enact the Preventing Medicare Telefraud Act's NPI provisions. Provider identity integrity costs nothing to enforce and removes the foundational mechanism of signature-mill fraud.
- Fund WISeR expansion contingent on AMA guardrails. The AI pre-payment screening model has significant promise but needs physician-guideline alignment and rapid appeals before national rollout.
- Mandate quarterly telehealth data transparency in any permanent telehealth legislation. Sunlight remains the most cost-effective fraud deterrent available.
- Issue guidance implementing the established-relationship tiered framework. CMS has existing authority to stratify audit intensity and pre-payment review triggers based on relationship status and billing-pattern risk.
- Implement a beneficiary confirmation system for high-value orders generated through new-patient telehealth encounters — analogous to the EVV model that improved personal care fraud detection.
- Accelerate HHS AI Strategy deployment for claims analytics. The December 2025 HHS AI Strategy explicitly calls for applying AI to health program integrity. Telehealth anomaly detection is the highest-ROI application given documented fraud concentration.
A Solvable Problem
For Medicare beneficiaries managing serious chronic conditions, telehealth is not going away — Congress extended it through 2027, and the AMA, major academic medical centers, and bipartisan legislative coalitions are aligned on permanent access. The clinical evidence supports virtual care in established relationships.
The ideal framework is not a tradeoff between access and integrity. It is a system sophisticated enough to extend the full benefits of telehealth to the cancer patient monitoring his PSA with an oncologist who has treated him for a decade, while simultaneously making the Medicare system inhospitable to the telehealth mill that has never met the patient it is billing for. We have the data, the AI tools, the legislative proposals, and the clinical evidence to build that system. The remaining variable is political commitment.
What patients can do in the meantime is be part of the solution. Reading the Medicare Summary Notice, reporting unfamiliar charges, and documenting telehealth encounters — noting the date, provider, platform, and clinical discussion — creates a personal record that strengthens the system's integrity and contributes to a surveillance network that depends on beneficiary participation.
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