In a report issued by OIG in August of 2021, OIG alleged that for Chronic Care Management (CCM) services, “providers billed for and received overpayments totaling $1,918,278, and beneficiaries were required to pay a total of up to $540,680 in Medicare cost sharing” for these services which they did not pay. OIG recommends, and CMS agrees, that it will seek recovery of the overpayment amounts from providers and will instruct providers to refund the cost share amounts that the beneficiaries were required to cover.

CCM consists of “management and support services provided by clinical staff, under the direction of a physician or other qualified health care professional, to a patient.” Specifically, the “services include establishing, implementing, revising, or monitoring the care plan, coordinating the care of other professionals and agencies, and educating the patient or caregiver about the patient’s condition, care plan, and prognosis.”

Prior to 2017, CCM services did not distinguish between complex and non-complex. Effective January 1, 2017, CMS created a separate category for complex CCM to allow complex chronic care services to be billed separately. (81 Fed. Reg. 80170, 80244-80245, 80349, 80364 (Nov. 15, 2016).) Non-complex CCM can be billed once per month per member after the clinical staff furnishes at least 20 minutes of care management services at the direction of a physician. Complex CCM can be billed once per month per member once an initial 60 minutes of care management services are provided and can be billed in subsequent increments of 30 minutes. However, this incremental complex CCM cannot be submitted if a physician has submitted a claim for noncomplex CCM.

During its audit, OIG claims to have reviewed 50,192 CCM claims from calendar years 2017 and 2018 and 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 month. OIG also allegedly identified 10,882 claims that resulted in $438,262 in overpayments for instances in which the same provider billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods. Lastly, OIG purportedly 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.

CMS states that its Medicare contractors will be seeking recovery of the overpayment amounts. To this end, CMS also states that it will be notifying appropriate providers of the potential overpayments and tracking returned overpayments that are made in accordance with the 60-day rule and OIG’s recommendation. Moreover, CMS stated that, since the audit “it has implemented claims processing controls, including system edits, to prevent and detect these types of overpayments” going forward.

A copy of OIG’s report can be found here.