Deeper Than the Headlines: Overpayments Identified by the OIG for Chronic Care Management Services

On January 1, 2015 CMS established a policy for Medicare for chronic care management (CCM) services to be paid under the Medicare Physician Fee Schedule. Specifically, for those services rendered to beneficiaries whose medical conditions meet certain criteria. Before that effective date, physicians could not bill separately for non face-to-face care management services provided to these beneficiaries.

The OIG has sensed that CCM payments are at a high risk for overpayments when compared to payments for more established Medicare services. This can be translated to the fact that CCM services are still a relatively new category of Medicare-covered services, plus they have multiple restrictions on when and how they can be billed. The categorization of these services also means that sufficient monitoring may not be in place to ensure compliance with applicable requirements.

With this in mind, the OIG conducted an audit of these services, with the objective of determining whether physician and outpatient payments made by CMS for CCM services complied with Federal requirements.

Background: CCM services, explained.

CCM involves the provision of at least 20 minutes per month of non face-to-face services to Medicare beneficiaries who have two or more chronic conditions. These chronic conditions are expected to last at least 12 months, or until the death of the beneficiary, and place the beneficiary at significant risk of death, acute exacerbation or decompensation, or functional decline. On the policy’s effective date, Medicare began allowing physicians and nonphysician practitioners to bill for CCM under the Medicare PFS using CPT code 99490.

Federal guidelines state that CCM services are provided on a per-calendar month basis.  When CCM services are not provided personally by the physician, they may be provided by clinical staff at the direction of the physician.

A physician may bill for CCM services only once per month for a beneficiary, and only one physician and one facility may bill for CCM services each month for the beneficiary. Additionally, some of the CCM billing requirements and certified EHR requirements include:

• The clinical staff furnished at least 20 minutes of care management services under the direction of the physician during the calendar month.
• The physician obtained beneficiary consent to provide CCM services and bill Medicare for those services.
• The physician meets all scope-of-service elements contained in the physician fee schedule.
• The physician uses a certified EHR system.

How the OIG conducted Their Review

The OIG reviewed the Federal requirements for CCM services and CMS’s internal controls for Calendar Years 2015 and 2016. They reviewed these CCM services in order  to determine whether CMS’s controls prevented overpayments by denying unallowable payments. To conduct their audit, the OIG used computer matching, data mining, and other data analysis techniques to identify overpayments and overlapping services. The OIG’s audit included 3,171,303 CCM claims submitted by billing physicians, totaling $100,604,601 in payments, and 80,966 CCM claims submitted by outpatient facilities totaling, $2,856,635 in payments.

The OIG Findings

According to the OIG report’s findings, physician and outpatient payments made by CMS for CCM services provided during the review period showed some discrepancies. In total, there were 20,165 claims that did not comply with Federal requirements, resulting in $640,452 in overpayments.

Specifically, the OIG identified 14,078 claims that resulted in $436,877 for instances in which physicians or facilities billed CCM services more than once for the same beneficiary, for the same service period. In other cases, the same CCM services were billed by a single physician or facility. And still in other cases, the same CCM services were billed by more than one physician or facility.

The OIG  identified an additional 6,087 claims that resulted in $203,575 in overpayments from instances where the same physician billed for both CCM services and overlapping care management services for the same beneficiaries. Of these 20,165 claims, beneficiaries were overcharged a total of $173,495 in cost sharing. Furthermore, the OIG identified 37,124 claims, totaling $1,162,562 in potential overpayments, for instances in which a CCM service was billed by an outpatient facility but a corresponding claim was not submitted by a physician. The OIG stated they are setting aside these potential overpayments for review and determination by CMS. Additionally, for these 37,124 claims, the beneficiaries themselves may have been overcharged a total of $373,726 in cost sharing.

The OIG Recommendations

As a result of the audit, the OIG recommended to CMS that they:

Recoup $640,452 from providers, and instruct them to refund overcharges totaling up to $173,495 to beneficiaries, consisting of:

• $436,877 in overpayments to providers that billed for the same CCM services for the same beneficiaries, and up to $121,573 in overcharges to these beneficiaries.
• $203,575 in overpayments to providers that billed for both CCM services and overlapping care management services for the same beneficiaries, and up to $51,922 in overcharges to these beneficiaries.

Review the 37,124 outpatient claims totaling $1,162,562 in potential overpayments to determine whether the outpatient facilities met the requirement to bill for CCM services and:

• Recoup any overpayments from outpatient facilities.
• Instruct the outpatient facilities to refund corresponding overcharges to beneficiaries.

Implement claim processing controls, including system edits, to prevent and detect overpayments for CCM services.

Naturally, CMS agreed with the OIG findings and recommendations. So, if your compliance program is responsible for managing the billing of any CCM services, it would be wise to audit these services and look for similar risks to those that were uncovered through this latest audit conducted by the OIG.