OIG Audit of Chronic Care Management Services Costing Trust fund Millions of Dollars

Effective January 1, 2017, the Centers for Medicare & Medicaid Services (CMS) broke off (or unbundled) complex chronic care management (CCM) services from non-complex CCM services and began paying separately for complex CCM services. Although the scope of service and billing requirements are the same for non-complex CCM as for complex CCM, the two types of services differ as to clinical staff time, medical decision-making, and care planning – key elements in determining the value attributed to codes for payment rate setting. CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments.

The Office of the Inspector General released a report on August 6, 2021 summarizing the results of the audit they performed of these services to determine whether payments made by CMS to providers for CCM services rendered during calendar years (CYs) 2017 and 2018 complied with Federal requirements. What they found was that not all payments made by CMS to providers for non-complex and complex CCM services rendered during CYs 2017 and 2018 complied with Federal requirements, resulting in $1.9 million in overpayments associated with 50,192 claims. They identified 38,447 claims resulting in $1.4 million in overpayments for instances in which providers billed noncomplex or complex CCM services more than once for the same beneficiary for the same service period. They also identified 10,882 claims that resulted in $438,262 in overpayments for instances in which the same provider billed for both non-complex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods. Further, they identified 863 claims that resulted in $52,086 in overpayments for incremental complex CCM services that were billed along with complex CCM services that were identified as overpayments. For these 50,192 claims, beneficiaries’ cost sharing totaled up to $540,680!

These errors occurred because CMS did not have claim system edits to prevent and detect overpayments.

Patient visits processed by RemitOne™ accurately capture encounter data at the point of care and translate it into a correctly coded and paid claim which reduces claims error rates and denials. By integrating a clean-claims processing tool on the front end, before a claim is sent to the payor, RemitOne™ drastically reduces the need for CMS to perform payor claim edits or reviews. Through the use of innovative technology, RemitOne™ lowers the administrative cost of healthcare by eliminating instances of fraud, waste, and abuse of Medicare trust fund dollars.

Contact our team at info@mccremitone.com to find out how you can utilize RemitOneTM to address compliance issues and improper payments.

To see more about MCC and RemitOne, visit our documentary segment that aired on CNBC here: https://www.mccremitone.net/r1video/MCC_03.mp4.