OIG Chronic Care Management Audit Reveals Overpayments: What to Know

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OIG Chronic Care Management Audit Reveals Overpayments: What to Know
by Daniel Tashnek

The Office of Inspector General (OIG) recently announced it had completed an audit of payments for chronic care management (CCM) services. The results of this audit have short- and long-term implications for providers of CCM services and for the vendors of CCM software that support those providers.


Big Picture: CMS reaffirmed its support and future coverage of chronic care management services in its recent proposed rule concurrently with this OIG audit of historic payments for improperly coded or documented CCM services. Taken together, this shows that while CMS is advancing the reimbursement and other incentives for performing care management services, it is also making sure that those incentives are not used by providers that fail to follow the rules and requirements. Training providers and staff on CCM requirements and using a CCM software that enforces compliance are crucial to the long-term health of any care services program and to avoid expensive audits and clawbacks.

Here are some of the key takeaways from the chronic care management audit.

1. What the chronic care management audit looked at

The OIG audit covered more than 7.8 million claims submitted by physicians and more than 240,000 claims submitted by hospitals for noncomplex and complex chronic care management services provided in 2017 and 2018.

2. Why CMS performed the CCM audit

CMS aimed to determine whether payments made by the agency for the two types of chronic care management services — noncomplex and complex — during 2017 and 2018 complied with federal requirements. As OIG notes, "CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments." This audit expands on the findings of a previous audit that found CMS lacked sufficient controls to ensure Medicare payments for noncomplex CCM services during 2015 and 2016 complied with federal requirements.

3. What the latest chronic care management audit found

The audit determined that there were $1.9 million in overpayments associated with about 50,000 claims for noncomplex and complex chronic care management services rendered during 2017 and 2018. This is broken down as follows:

  • About 38,500 claims resulting in $1.4 million in overpayments for instances when providers billed noncomplex or complex CCM services more than once for the same beneficiary for the same service period.
  • About 11,000 claims that resulted in roughly $448,000 in overpayments for instances in which the same provider billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods.
  • About 850 claims that resulted in roughly $52,000 in overpayments for incremental complex CCM services that were billed along with complex CCM services that we identified as overpayments.

From these claims, beneficiaries' cost sharing totaled up to about $541,000. OIG noted that the overpayment errors occurred because CMS lacked claim system edits to prevent and detect overpayments.

4. What OIG recommended

OIG issued several recommendations for CMS, including the following:

  • Direct Medicare contractors to recover the $1.9 million for claims within the reopening period.
  • Instruct providers to refund up to ~$541,000 which beneficiaries were required to pay.
  • Notify appropriate providers to exercise reasonable diligence in identifying, reporting, and returning overpayments in accordance with the 60-day rule. The 60-day rule, created by the Affordable Care Act, requires providers to use reasonable diligence to identify overpayments via proactive compliance activities to monitor for overpayments and investigate potential overpayments in a timely manner.
  • Implement claim system edits to prevent and detect future overpayments for noncomplex and complex chronic care management services.

What the Chronic Care Management Audit Means to Providers

In the short term, providers of chronic care management services contacted by Medicare contractors will need to take the necessary steps to refund the overpayments to Medicare and any affected beneficiaries. Access the full OIG audit report here.

In the longer term, the chronic care management audit's results suggest that CMS will be stepping up its oversight of the Medicare chronic care management program — especially considering the agency's plans to support the growth of CCM, including increasing reimbursement for 2022. Providers must ensure that they are properly coding and billing for chronic care management services or they could face compliance violation penalties. This makes it particularly important that providers ensure the software they are using to help bill for CCM services places compliance as a top priority.

To learn how Prevounce delivers personalized, CMS-compliant CCM solutions that fit seamlessly into a provider's workflow, schedule a demo today.

Read the Guide: Building a Successful Chronic Care Management Program

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