Some Texas physicians and outpatient facilities might have to refund payments they received for chronic care management (CCM) services performed during 2015 and 2016 under the Medicare Physician Fee Schedule, federal officials said.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently reviewed all paid claims nationwide for CCM services for both years to determine whether payments made by the Centers for Medicare & Medicaid Services (CMS) met federal requirements.
The audit identified $640,452 in overpayments associated with 20,165 claims, the OIG said.
Of those payments:
- $436,877 came from 14,078 claims in which physicians or facilities billed CCM services more than once for the same beneficiaries for the same service period; and
- $203,575 came from 6,087 claims in which the same physician billed for both CCM services and overlapping care management services for the same beneficiaries.
“For these 20,165 claims, beneficiaries were overcharged a total of up to $173,495 in cost sharing,” the OIG said.
In addition, the audit identified 37,124 claims totaling $1.2 million 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.
“For these 37,124 claims, beneficiaries may have been overcharged a total of up to $373,726 in cost sharing,” OIG said.
The agency did not specify how many Texas physicians or outpatient facilities might have to refund payments for those services.
“These errors occurred because CMS did not have adequate controls in place, including claim system edits, to identify and prevent overpayments,” OIG said.
In 2015, Medicare began paying separately on a monthly basis for CCM services, which are non-face-to-face activities by physicians or clinical staff to manage and coordinate the care of patients with two or more conditions.
The OIG said CMS would take corrective actions and will instruct its Medicare Administrative Contractors to recover overpayments and instruct providers to refund any deductible or coinsurance amounts consistent with Medicare’s payment laws, policies, and procedures. CMS also will implement claim processing controls, including system edits, to prevent and detect future overpayments for CCM services.
For complete details, refer to the OIG report. Find more information about CCM implementation and compliance on CMS’ Care Management page as well as its Connected Care Chronic Care Management Resource page.