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Here are excerpts:
Report in Brief
Why OIG Did This Audit
Our objective was to determine whether payments made by CMS to providers for noncomplex and complex CCM services rendered during calendar years (CYs) 2017 and 2018 complied with Federal requirements.
How OIG Did This Audit
Our audit covered over 7.8 million claims submitted by physicians and over 240,000 claims submitted by hospitals for non-complex and complex CCM services provided in CYs 2017 and 2018. Paid physician and hospital claims for those services for CYs 2017 and 2018 totaled
What OIG Found
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
These errors occurred because CMS did not have claim system edits to prevent and detect overpayments.
What OIG Recommends and CMS Comments
We recommend that CMS direct the Medicare contractors to: (1) recover the
CMS concurred with all of our recommendations and described corrective actions for the recovery of the overpayments we identified and the refund of amounts overcharged to beneficiaries. CMS also stated that since our audit period, it has implemented claims processing controls, including system edits, to prevent and detect these types of overpayments. CMS added, though, that some providers may not be liable for the overpayments because they could be found to be without fault under the provisions of the Social Security Act. Our recommendations conform to CMS provisions that the Medicare contractors make determinations regarding the recovery of overpayments.
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TABLE OF CONTENTS
INTRODUCTION ... 1
Why We Did This Audit ... 1
Objective ... 2
Background ... 2
Payment Differences Based on Setting ... 2
Non-complex Chronic Care Management ... 4
Complex Chronic Care Management ... 5
Overlapping Care Management Services ... 6
How We Conducted This Audit ... 6
FINDINGS ... 7
Payments for Multiple Claims for the Same Beneficiary ... 8
Payments for Claims Containing Chronic Care Management Services That Overlapped With Other Care Management Services ... 11
Payments for Incremental Complex Chronic Care Management Services Associated With Overpayments for Complex Chronic Care Management Services Identified by
LACK OF CLAIM SYSTEM EDITS FOR CHRONIC CARE MANAGEMENT SERVICES ... 14
RECOMMENDATIONS ... 14
CMS COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ... 15
A: Audit Scope and Methodology ... 17
B: CMS Comments ... 19
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WHY WE DID THIS AUDIT
Initially, CMS covered CCM services without distinguishing between: (1) those of lesser complexity and lower time consumption and (2) those of more complexity and time consumption. Under new Federal rules that became effective
The effect of this change was to allow health care providers (including hospitals and physicians) to receive payments for the relatively more complex and time-consuming services rendered under complex CCM.
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 the amount of clinical staff service time provided, the complexity of medical decision-making, and the nature of care planning that was performed.
CCM services are still a relatively new category of Medicare-covered services and have multiple restrictions on when and how they can be billed. CCM payments are at higher risk for overpayments compared with payments for more established Medicare services because CMS generally needs time to conduct provider education and create and test controls to ensure that claims for new services conform to the restrictions. The recent unbundling of these services also means that sufficient controls may not be in place to ensure compliance with applicable requirements. A previous audit determined that CMS did not have sufficient controls in place to ensure that Medicare payments for non-complex CCM services during calendar years (CYs) 2015 and 2016 complied with Federal requirements./2
For this audit, we expanded on that previous work to review both non-complex and complex CCM services paid after CMS unbundled them.
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Our objective was to determine whether payments made by CMS to physicians and hospitals (providers) for non-complex and complex CCM services rendered during CYs 2017 and 2018 complied with Federal requirements.
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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 A provides inpatient hospital insurance benefits and coverage of extended care services for patients after hospital discharge. Medicare Part B provides supplementary medical insurance for medical and other health services, including coverage of hospital outpatient services. CMS contracts with Medicare contractors to, among other things, process and pay claims submitted by providers.
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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. Of the 8,061,572 claims we reviewed, 50,192 claims did not comply with Federal requirements, resulting in
Specifically, of the 50,192 claims totaling
* 38,447 claims that resulted in
* 10,882 claims that resulted in
* 863 claims that resulted in
For these 50,192 claims, beneficiaries' cost sharing totaled up to
Table 1 on the following page summarizes these findings and breaks out, for each finding, the amount of overpayments made by CMS and the amount of overpayments made by beneficiaries.
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[See link at end of text for Table 1: Claims Questioned]
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The errors we identified occurred because CMS did not have claim system edits to prevent and detect overpayments. Additionally, as noted in our previous audit (footnote 2), CMS did not have CCM-specific claim system edits in place.
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We recommend that the
* recover the
* based on the results of this audit, 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 claim system edits to prevent and detect overpayments for noncomplex and complex CCM services.
We also recommend that the
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View full report at https://oig.hhs.gov/oas/reports/region7/71905122.pdf