OIG: Challenges and Opportunities in Delivering Telehealth to Behavioral Health Medicaid Enrollees

Much of the nation’s behavioral health care has gone virtual since the beginning of the pandemic. And while it has been a convenient way to ensure that care goes uninterrupted, there is still room for improvement for states to strengthen their telehealth capacities for Medicaid enrollees.

That was what the Office of Inspector General (OIG) asserted in two new reports, which assessed states where telebehavioral health services are administered to residents receiving Medicaid.

The reports were part of a four-part set that OIG released earlier this week, with one report investigating problems that states have encountered while providing telehealth services to Medicaid enrollees. Conversely, a second report focused on opportunities for strengthening the evaluation and oversight of remote care.

“States expanded their use of telehealth to help meet the needs of enrollees while also reducing the risks from community spread of the virus,” both reports noted. “As the Nation confronts the psychological and emotional impact of COVID-19, the use of telehealth will be important in addressing behavioral health needs for Medicaid enrollees.”


Medicaid directors from 37 states were surveyed for both reports, where behavioral health care services were delivered virtually through managed care organizations (MCOs). Both surveys assessed the capabilities of telehealth at the state level as of January and February 2020.

The surveys also included structured interviews with relevant stakeholders coming from the state and federal level, as well as from MCOs. Recommendations for action were made to the Centers for Medicare & Medicaid Services (CMS) for both reports.

Telebehavioral health can be used to provide services including mental health assessments, behavioral therapy and medication management. Telehealth is often delivered live by video between a behavioral care provider and a patient, although states may allow it to occur entirely by audio, text or email.


In regards to challenges states have experienced with telebehavioral health, participants were asked to discuss common problems encountered. Participants listed a number of challenges such as inadequate training for providers and enrollees, limited internet access connectivity, privacy and security concerns, as well as the cost of telehealth infrastructure and interoperability issues.

OIG recommended that CMS share and facilitate information among different states, which can include examples of how certain states previously encountered and fixed such problems. Another example OIG suggested was CMS collecting and disseminating information from states that have experienced such problems during the pandemic, along with strategies that were subsequently enacted as remedies.

CMS concurred with the recommendation.

“CMS has an important role to play in facilitating the exchange of information among States to improve the use of telehealth for behavioral health services,” the report noted. “Sharing information among States will help ensure that States realize the benefits of telehealth and make informed decisions about how to address challenges with using telehealth.”

When it came to opportunities for strengthening evaluation and oversight of telebehavioral health, survey participants were asked about whether states could effectively distinguish between services provided virtually and those in-person. Participants were also asked about methods used to track telehealth services, such as procedure codes.

Participants were further queried about the ability of states to evaluate the effects of telehealth on delivery points like access, cost and quality of services. Additionally, participants were surveyed about the work of states in monitoring and overseeing telebehavioral health services through such means as analyses and audits.

OIG found that while most states could distinguish services being provided via telehealth, a few reported being unable to do so. Only a few states evaluated the effects of their telehealth offerings, which found access to services increasing as costs decreased. Additionally, the report found that many states do not conduct telehealth monitoring and oversight, despite concerns about fraud, waste and abuse.

For states that were unable to identify telebehavioral health services with certainty, OIG recommended that CMS ensure that indicators are implemented by states to distinguish those services from in-person care. CMS concurred with OIG on the recommendation.

OIG also recommended that CMS conduct evaluations evaluating the effects of telehealth on behavioral health services, as well as supporting efforts of states to do so. Finally, OIG said that CMS could help states oversee telehealth services, as well as monitor for fraud, waste and abuse. CMS did not indicate whether it concurred with either of the recommendations.

“CMS and State efforts to evaluate and oversee telehealth are critical to meeting Medicaid enrollees’ behavioral health needs and to safeguarding the Medicaid program from potential fraud, waste, and abuse,” OIG said in the report. “These efforts are particularly important as the telehealth landscape continues to evolve.”

Medicaid is the nation’s single largest payer of behavioral health services. Among Medicaid enrollees, one in five have been diagnosed with behavioral health conditions, according to the nonpartisan Medicaid and CHIP Payment and Access Commission.

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