Medicare Payments for Transitional Care Management Services Generally Complied With Federal Requirements, but Some Overpayments Were Made

Date Issued

Wednesday, July 7, 2021

Submitting OIG

Department of Health & Human Services OIG

Other Participating OIGs

Department of Health & Human Services OIG

Agencies Reviewed/Investigated

Department of Health & Human Services

Report Number

A-07-17-05100

Report Description

Federal RequirementsPhysicians who bill for TCM services are restricted from billing for restricted overlapping care management services (77 Fed. Reg. 68985 and 68990 (Nov. 16, 2012)). Therefore, these overlapping care management services may not be billed for services provided during the same 30-day TCM service period for the same beneficiary.According to CMS officials, in these instances the first claim submitted should be paid and the second claim submitted should be denied.Physicians who bill for TCM services are restricted from billing for restricted overlapping care management services (77 Fed. Reg. 68985 and 68990 (Nov. 16, 2012)). Therefore, these restricted overlapping care management services may not be billed for services provided during the same 30-day TCM service period for the same beneficiary.According to CMS officials, in these instances the first claim submitted should be paid and the second claim submitted should be denied.

Report Type

Audit

Number of Recommendations

Questioned Costs

Funds for Better Use

Open Recommendations

This report has 2 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
270869	No	$0	$0
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.
270870	No	$0	$0
Based on the results of this audit, we recommend that the Centers for Medicare & Medicaid Services implement claims processing controls, including system edits, to prevent and detect overpayments for TCM.