HR 1785119th CongressIn Committee

Preventing Medicare Telefraud Act

Introduced: Mar 3, 2025

Standard Summary

Comprehensive overview in 1-2 paragraphs

The Preventing Medicare Telefraud Act would tighten when Medicare pays for certain high-cost durable medical equipment (DME) and high-cost laboratory tests ordered via telehealth. Specifically, it would bar payment for these items ordered by a physician or other qualifying practitioner via telehealth unless the patient had an in-person visit at least once in the prior six months. The bill also requires definitions of what counts as “high-cost” DME and laboratory tests to be set by the CMS Administrator and imposes audits of providers with a high share of telehealth-based orders. Additionally, it would require claims for separately billable telehealth services to be submitted with the provider’s National Provider Identifier (NPI). In short, the bill aims to curb telehealth-based fraud or overuse for expensive equipment and tests by tying payment to in-person visits, establishing oversight, and tightening claim submission.

Key Points

1High-cost DME payment restriction: Payment for high-cost durable medical equipment ordered via telehealth is prohibited unless the ordering clinician provided an in-person service at least once in the prior 6 months. CMS would define which equipment counts as “high-cost.”
2High-cost lab tests: Payment for high-cost laboratory tests ordered via telehealth is prohibited unless the ordering clinician provided an in-person service at least once in the prior 6 months. CMS would define which tests qualify as “high-cost.”
3Audits for telehealth-heavy prescribers: Starting about six months after enactment, Medicare contractors will identify clinicians with at least 90% of their DME or laboratory test claims prescribed via telehealth in the prior year and will audit those claims for compliance.
4NPI requirement for telehealth claims: Payment for separately billable telehealth services may not be made unless the claim is filed under the provider’s national provider identifier (NPI).
5Implementation timing: The payment limitations for high-cost DME and high-cost lab tests would take effect 180 days after enactment, giving some lead time before rules apply.

Impact Areas

Primary group/area affected: Medicare beneficiaries who receive high-cost DME or high-cost laboratory tests ordered via telehealth, and the clinicians/practitioners who order those services.Secondary group/area affected: Healthcare providers and suppliers of high-cost DME and laboratories, Medicare Administrative Contractors (MACs) responsible for audits, and telehealth service infrastructure.Additional impacts: Potential changes in telehealth utilization patterns for expensive items, increased administrative requirements for providers (in-person visits, precise NPI-based billing), and possible effects on access to telehealth for patients who rely on remote care but may have barriers to in-person visits.The bill defines “high-cost” items and tests to be determined by CMS, which leaves some specifics to future rulemaking.The in-person visit requirement is designed to ensure some direct patient interaction before expensive items or tests are prescribed via telehealth.The bill emphasizes auditing high-volume telehealth prescribers, which could lead to increased scrutiny of telehealth practices beyond just high-cost items.

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