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OIG: No CCM oversight by CMS = overpayments and overcharges in 2015 and 2016

Some early adopters of chronic care management (CCM) received overpayments because inadequate oversight allowed overlapping care management services.
The HHS Office of Inspector General (OIG) published an audit that focused on claims for code 99490 in 2015 and 2016 — the first two years of the code’s existence — and the title of the audit summarizes the findings: Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Management Services.
“The errors we identified occurred because CMS did not have adequate controls in place, including claim system edits, to identify and prevent overpayments. CMS officials told us that prior to our audit, CMS had developed potential CCM-specific claim system edits; these officials added that CMS has no current plans to implement them,” the OIG stated in the Nov. 13 report.
Auditors found three types of overlapping errors and added up overpayments to Medicare and overcharges to patients who received the improper services:
  1. Providers or facilities billed CCM more than once for the same patient in the same month. Medicare: $313,485. Patients: $90,068.
  2. Multiple providers billed CCM for the same patient in the same month. Medicare: $123,392. Patients: $31,505.
  3. A physician billed for CCM and an overlapping care management service such as home health care supervision in the same month. Medicare: $203,575. Patients: $51,922.
It amounts to $640,452 in overpayments that CMS says in its response to OIG that it will recoup from providers and $173,495 in improper charges that providers will have to refund to patients.
The OIG called out another $1,162,562 worth of CCM claims by outpatient facilities — approximately 47% of all such claims — because there was no corresponding physician claim during the same service period. According to the OIG, this could be a sign “that both the physician and the facility may not have met CCM requirements.”
The report also contains a warning for practices that bill CCM and transitional care management (TCM). The OIG is auditing 15,504 CCM claims that were billed for the same patient by the same provider during the same month as a TCM service. (Note: This will cease to be a problem in 2020, when CMS allows TCM and CCM to be billed together. See our Physician Fee Schedule final rule coverage [subscription] for details.) The results of that audit will appear in an upcoming report.
Care management coverage history
This blog post prompted a trip down memory lane to see when various care management codes were created and how Medicare’s coverage status has changed through the years. One thing that became clear, there's been a lot of change since TCM was first introduced. Here’s a quick overview.
TCM (99495, 99496) — Active
Complex CCM (99487, 99488, 99489) — Bundled
CCM (99490) — Active
Complex CCM (99448) — Deleted
Complex CCM (99487, 99489) — Active
Blog Tags: CMS, OIG, overpayments
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