HHS I.G. Audit: 'Medicare Payments for Transitional Care Management Services Generally Complied With Federal Requirements'

WASHINGTON, July 9 -- The Health and Human Services Inspector General issued the following audit report (No. A-07-17-05100) entitled "Medicare Payments for Transitional Care Management Services Generally Complied With Federal Requirements, but Some Overpayments Were Made" filed under the Centers for Medicare and Medicaid Services:

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Here are excerpts:

Report in Brief

Why OIG Did This Audit

Effective January 1, 2013, the Centers for Medicare & Medicaid Services (CMS) established a separate fee schedule for payments under the Medicare Physician Fee Schedule (PFS) for transitional care management (TCM) services rendered to beneficiaries whose medical conditions meet Medicare requirements. Medicare payments made under this PFS are at a higher risk of overpayments because TCM services are still a relatively new category of Medicare-covered services and because there are multiple restrictions on when and how those services can be billed.

Our objective was to determine whether payments made to physicians and qualifying non-physician-practitioners (collectively referred to as "physicians" for this report) for TCM services provided during calendar years (CYs) 2015 and 2016 complied with Federal requirements.

How OIG Did This Audit

Our audit covered almost 1.8 million TCM claims submitted by physicians totaling $249.5 million in payments made in CYs 2015 and 2016. We reviewed Federal requirements for TCM services and CMS's internal controls specific to claims containing TCM services.

What OIG Found

Payments made to physicians for TCM services provided during CYs 2015 and 2016 generally complied with Federal requirements, but we identified almost $1.7 million in overpayments associated with 13,577 claims (that were outside the reopening and recovery period) for instances in which multiple physicians billed for TCM services for a beneficiary's same 30-day TCM service period and for instances in which a physician billed on different dates for TCM and restricted overlapping care management services provided during the same 30-day TCM service period for the same beneficiary. These overpayments represented only 0.006 percent of the total TCM payments made in our audit period. We also identified 853 claims that were outside the reopening and recovery period, and that totaled at least $74,275 in unallowable services, for instances in which a physician submitted claims on the same date for TCM and restricted overlapping care management services that were rendered for the same beneficiary during a single 30-day TCM service period. We were not able to determine which of these claims were overpayments. CMS did not have controls in place, to include claim system edits, to prevent and detect multiple TCM services provided to beneficiaries and to identify instances of overlapping care management.

What OIG Recommends and CMS Comments

We recommend that CMS: (1) notify appropriate providers (i.e., those for whom CMS determines that this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation; and (2) implement claims processing controls, including system edits, to prevent and detect overpayments for TCM services.

CMS concurred with both of our recommendations and described corrective actions that it had taken or planned to take. CMS stated that it would analyze our findings to identify appropriate providers and suppliers to notify of potential overpayments. CMS also referred to payment policies that it has changed since our audit period and said it would evaluate opportunities to implement claims processing controls to prevent and detect overpayments for TCM services, as well as the feasibility and cost effectiveness of system edits.

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TABLE OF CONTENTS

INTRODUCTION ... 1

Why We Did This Audit ... 1

Objective ... 1

Background ... 1

Medicare Administrative Contractors ... 1

Transitional Care Management ... 2

Prohibition Against Billing of Multiple Transitional Care Management Services ... 3

Restricted Overlapping Care Management Services ... 4

The 60-Day Rule and 6-Year Lookback Period ... 5

How We Conducted This Audit ... 5

FINDINGS ... 6

Multiple Transitional Care Management Services Billed by Different Physicians for the Same 30-Day Transitional Care Management Service Period ... 6

Federal Requirements ... 6

Multiple Physicians Billed for Transitional Care Management Services for the Same Beneficiary for the Same 30-Day Transitional Care Management Service Period ... 7

Transitional Care Management Services and Restricted Overlapping Care Management Services Billed by the Same Physician for the Same 30-Day Transitional Care Management Service Period ... 7

Federal Requirements ... 7

The Same Physician Billed for Transitional Care Management and Restricted Overlapping Care Management Services for the Same Beneficiary for the Same 30-Day Transitional Care Management Service Period ... 8

Transitional Care Management and Restricted Overlapping Care Management Services Claims Submitted by the Same Physician on the Same Date ... 8

Federal Requirements ... 8

Transitional Care Management and Restricted Overlapping Care Management Services Claims Submitted on the Same Date for Services Rendered During a Single 30-Day Transitional Care Management Service Period ... 9

No System Edit To Prevent and Detect Overpayments for Transitional Care Management Services ... 10

RECOMMENDATIONS ... 10

CMS COMMENTS ... 10

APPENDICES

A: Audit Scope and Methodology ... 12

B: CMS Comments ... 14

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INTRODUCTION

WHY WE DID THIS AUDIT

Effective January 1, 2013, the Centers for Medicare & Medicaid Services (CMS) established a separate fee schedule for payments under the Medicare Physician Fee Schedule (PFS) for transitional care management (TCM) services rendered to beneficiaries whose medical conditions meet Medicare requirements. Medicare payments made under this PFS are at a higher risk of overpayments because TCM services are still a relatively new category of Medicare-covered services and because there are multiple restrictions on when and how those services can be billed.

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OBJECTIVE

Our objective was to determine whether payments made to physicians and qualifying non-physician-practitioners (NPPs) (collectively referred to as "physicians" for this report) for TCM services provided during calendar years (CYs) 2015 and 2016 complied with Federal requirements.

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BACKGROUND

Under the provisions of Title XVIII of the Social Security Act (the Act), the Medicare program provides health insurance for people aged 65 and over, people with disabilities, and people with permanent kidney disease. CMS administers the program. Medicare Part B provides supplementary medical insurance for medical and other health services, including coverage of hospital outpatient services.

Under the provisions of section 1848 of the Act, CMS is required to establish a fee schedule for physicians' services based on the relative resources used in furnishing a service to a beneficiary.

Under its Federal rulemaking authority, CMS established the Medicare PFS and publishes changes and revisions to the PFS annually, in the form of a Final Rule, in the Federal Register.

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FINDINGS

Payments made to physicians for TCM services provided during CYs 2015 and 2016 generally complied with Federal requirements, but we identified $1,660,677 in overpayments associated with 13,577 claims that were outside the reopening and recovery period./14

These overpayments represented only 0.006 percent of the total TCM payments made in our audit period. Specifically, we identified:

* 5,941 claims totaling $864,433 for instances in which multiple physicians billed for TCM services for a beneficiary's same 30-day TCM service period, and

* 7,636 claims totaling $796,244 for instances in which a physician billed on different dates for TCM and restricted overlapping care management services provided during the same 30-day TCM service period for the same beneficiary.

Additionally, we identified 853 claims that were outside the reopening and recovery period, and that totaled at least $74,275 in unallowable services, for instances in which a physician submitted claims on the same date for TCM and restricted overlapping care management services that were rendered for the same beneficiary during a single 30-day TCM service period.

For the 853 claims submitted on the same date, we were not able to determine which overlapping claims were allowable and which were overpayments. Specifically, we were not able to determine which claims were submitted first. According to CMS officials, in instances of overlapping care management services, the first claim submitted should be paid and the second claim submitted should be denied.

Although payments generally complied with Federal requirements, we identified errors that occurred because CMS did not have controls in place, to include claim system edits, to prevent and detect multiple TCM services provided to beneficiaries and to identify instances of overlapping care management.

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RECOMMENDATIONS

Based on the results of this audit, we recommend that the Centers for Medicare & Medicaid Services:

* notify appropriate providers (i.e., those for whom CMS determines that this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation; and

* implement claims processing controls, including system edits, to prevent and detect overpayments for TCM services.

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View full report at https://oig.hhs.gov/oas/reports/region7/71705100.pdf