OIG: Medicare, patients may have been overcharged for CCM services

Medicare overpaid providers $640,452 for chronic care management (CCM) services and may have overpaid outpatient facilities an additional $1.2 million for CCM, according to an Office of Inspector General (OIG) report released November 7.

Providers have been able to bill separately for non-face-to-face CCM since 2015. According to the OIG, CCM payments are at higher risk for overpayments when compared to more established services because they are relatively new. Additionally, CMS may not have sufficient monitoring in place to ensure CCM claims are compliant.

A physician can bill for CCM services once a month for a beneficiary. Only one physician and one facility can bill for CCM services per month for a beneficiary. Other requirements for billing for CCM services include the following:

• Clinical staff must furnish at least 20 minutes of care management services under the direction of the physician during the calendar month
• Th physician must meet all scope-of-service requirements contained in the Physician Fee Schedule
• The physician must obtain the beneficiary’s consent to provide CCM services and bill Medicare for those services
• The physician must use a certified EHR

The OIG reviewed physician and outpatient claims for CCM made in 2015 and 2016. The OIG discovered $436,877 in overpayments due to physicians or facilities billing for CCM services more than once per month per beneficiary. An additional $203,575 in overpayments were made for CCM services and overlapping care management services for the same beneficiaries.

The OIG also identified $1,162,562 in potential overpayments for claims in which a CCM service was billed by an outpatient facility, but a corresponding claim was not submitted by the physician. The OIG is recommending CMS review these claims. For these specific claims, beneficiaries may have been overcharged $373,726.

According to the report, the errors occurred because CMS did not have adequate controls in place. CMS had developed potential CCM-specific claim system edits, but the agency does not have plans to implement them, the report said.

The OIG recommended that CMS recoup the $640,452 in overpayments and review the potential $1.2 million in additional overpayments. The agency also recommended that CMS implement claim processing controls to prevent future CCM overpayments. CMS concurred with the OIG’s recommendations.

Organizations should review their policies for billing and claim edits for CCM services. The 2020 Medicare Physician Fee Schedule includes expanded CCM billing. Organizations should ensure that staff, for both facility and professional fee billing, are properly trained in CCM billing requirements. Organizations should be particular sensitive to billing errors that may result in overpayments charged to beneficiaries.