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The OIG Identifies Overpayments for CCM

The OIG Identifies Overpayments for CCM February 11, 2020

The OIG released a report that revealed Medicare made hundreds of thousands of dollars in overpayments for chronic care management (CCM) services which did not meet federal billing requirements.  The OIG report identified $640,452 in overpayments with $1.2 million in additional potential overpayments requiring further review by CMS.  The OIG also added CCM services to their active Work Plan.

Additionally, the 2019 Comprehensive Error Rate Testing (CERT) Report, released last month, identified a 66.2% payment error rate for CCM services.

Medicare provides reimbursement for CCM services when certain criteria are met which include:

  • Providing at least 20 minutes per month of non-face-to-face services 
  • Medicare beneficiary has two or more chronic conditions expected to last at least 12 months
  • The chronic conditions place the beneficiary at a significant risk of death, acute exacerbation, decompensation or functional decline
  • Services may only be billed once per month, per beneficiary
  • Only one physician and one facility may bill for CCM services each month per beneficiary
  • CCM may not be billed in addition to transitional care management, home health or hospice supervision or ESRD supervision services
  • Must obtain beneficiary consent to provide and bill Medicare for CCM services
  • Physician must use a certified EHR system

The overpayment errors identified by the OIG were due to the following:

  • Multiple claims by a single provider within the same month
  • Multiple claims by more than one provider within the same month
  • CCM claims billed in addition to other care management services

The OIG also identified a significant volume of hospital outpatient claims without a corresponding physician claim suggestive of additional overpayments.  This issue is currently under investigation.

Due to the significant volume of overpayment errors identified by both the OIG and CERT, we recommend conducting auditing and monitoring of your CCM services to confirm compliance with the Medicare billing rules.  HBE’s team has the expertise to assist you with auditing of CCM services as well providing customized education on appropriate documentation, coding and billing of CCM services. 

The complete OIG reported is located at https://oig.hhs.gov/oas/reports/region7/71705101.pdf

A summary of the CCM billing rules is located at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

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