Effective January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) established a policy for Medicare to pay under the Medicare Physician Fee Schedule for chronic care management (CCM) services rendered to beneficiaries whose medical conditions meet certain criteria. Effective January 1, 2017, CMS unbundled complex CCM from noncomplex CCM and began paying separately for complex CCM. Although scope of service and billing requirements are the same for noncomplex CCM as for complex CCM, the two types of services differ as to clinical staff time, medical decisionmaking, and care planning. CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments. This audit expands on the findings of a previous OIG audit.
Open Recommendations
| Recommendation Number | Significant Recommendation | Recommended Questioned Costs | Recommended Funds for Better Use | Additional Details | |
|---|---|---|---|---|---|
| 270984 | No | $0 | $0 | ||
| 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. | |||||
| 270985 | No | $0 | $0 | ||
| We recommend that the Centers for Medicare & Medicaid Services direct the Medicare contractors to implement claim system edits to prevent and detect overpayments for noncomplex and complex CCM services. | |||||
| 270986 | No | $0 | $0 | ||
| We recommend that the Centers for Medicare & Medicaid Services implement claim system edits at its level to prevent and detect overpayments for noncomplex and complex CCM services. | |||||
