Federal OIG Audits Find More CMS Chronic Care Management Overpayment: Providers & Clinics Must Pay Money Back

February 15, 2022


Recently CrossTx showcases a study authored by a team of experts from the University of Washington showcasing the important yet still not-well understood U.S. Centers for Medicare and Medicaid Services (CMS) Chronic Care Management (CCM) program. Initiated just in 2015, the authors of this study emphasized that the program starts to take off, but most eligible clinics remain to take advantage of the program.

While there have been few rumblings of CMS-based CCM audits they are in fact occurring. In fact, last year the U.S. Office of the Inspector General (OIG) executed an audit finding uncovering that Medicare was overpaying for CCM services, imposing costs on the program, its beneficiaries and ultimately the American taxpayer.

The first Audit?

Authored in 2019, OIG produced a report titled “Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Management Services.” https://oig.hhs.gov/oas/reports/region7/71705101.pdf  Led at the time by Gloria L. Jarmon Deputy Inspector General for Audit Service, the reports author, OIG found that in the first couple years of the CCM program $640,452 in overpayments associated with 20,165 claims led to the need for repayment.  The OIG declared “We identified 14,078claims that resulted in $436,877 in overpayments” in situation where providers or facilities “billed CCM services more than once for the same beneficiaries for the same service period.” Ultimately beneficiaries accrued $173,495 in cost sharing.

CrossTx reminds that only a sliver of a fraction of providers and clinics were making use of the program at this juncture.

Why the next Audit?

Based on the experiences of the previous audit and the introduction of new complexity, OIG sought to assess the levels of adherence to the CCM program. 

By January 1, 2017, CMS “unbundled complex CCM from non complex CCM” thereby making a separate payment stream for the complex CCM.   Although billing elements are comparable (e.g., scope of service and billing requirements) for both complex CCM and noncomplex CCM, the program varies by the allocation of clinical staff time, medical decision making and care planning.

OIG shared last year “CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments.”  This particular audit generated findings comparable to a previous audit.  

The Inspection

The OIG sought out to assess  whether CMS payments to providers of both non complex and complex CCM services rendered during calendar 2017 and 2018 adhered to the rules associated with the federal government.

What did they find?

Scouring over 7.8 million CCM claims from doctors as well as 240,000 hospital-originating claims for CCM services during the audit period, OIG discovered $1.9 million in overpayments associated with noncompliance with the federal CCM program requirements across 50,000 claims. What did this falter compliance cost beneficiaries?  $540,680.

What were some notable observations?

Of the $1.9 million total, approximately $1.4 million of the total was because providers inappropriately billed non complex or complex CCM services on more than one occasion or the same Medicare beneficiary.  Put another way the providers were double charging because they lacked the ability to efficiently and effectively differentiate between the two programs.

The complexity of the programs introduces risks for those organizations that don’t 1) maintain the expertise on the various programs 2) introduce policies and procedures for invoicing and 3) overuse the electronic health record due to a faulty assumption that such systems can easily demarcate the various programs, processes and invoicing parameters.   

Consequently another $438,000 were found in overpayments due to further overlapping of CCM and care management services offered to the same beneficiaries.   Additionally, the CMS should have rejected CCM claims associated with improper incremental complex CCM claims.

Explaining the errors OIG declared in its report “These efforts occurred because CMS did not have claim stem edits to prevent and detect overpayments”  Additionally complexity with the unbundling of complex and non complex CCM contributed to the situation.

The OIG raised a key point declaring:

“Although 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 clinical staff time, medical decision making and care planning” goes the report.

So, applying to the real world, if a doctor has already submitted a claim for non complex CCM they cannot submit a claim for incremental complex CCM.   The OIG reminds that this new program represents fertile grounds for overpayment.

What did the OIG recommend last year?  Actually, three take ways including:

1.  They seek to recover the $1.9 million for claims associated with the reopening period combined with the necessity that providers pay up refunds of $540,680.

2.   Notification to providers to support their ability to apply due diligence in their effort to scrutinize (and pay back if necessary) any overpayments in accordance with the 60—day rule.  OIG wants to ensure that any requirement for returned payments have been made. 

3.   Implement claim system edits in a bid to not only stop overpayment but also to recognize when it has occurred for both non complex and complex CCM services. Ideally articulates OIG the CMS should institute its own agency claims system edits.

CMS Collects

The OIG reports that CMS concurred with the audit findings and moved to recover the overpayment amounts from providers.  OIG reports some overall good news declaring “The audit report confirmed that CMS agreed with all recommendations and initiated actions to recover the overpayments. CMS also noted that since the audit period, it has improved its process by implementing system edits and claims processing controls to prevent overpayments.

“While CMS has not observed substantial rates of chronic care management overpayments, we continue to evaluate opportunities to implement claims processing controls to prevent and detect overpayments for both complex and non complex chronic care management services.”


A leader in the delivery of solutions that support the clinic and provider adherence with various federal transition to value programs, including CMS’ Chronic Care Management (CCM), CrossTx will continue to monitor CMS and other sources for relevant updates.  For a demonstration of the CrossTx solution contact us at marketing@crosstx.com

Daniel O’Connor, JD

Chief Business Officer

CrossTx, Inc. 



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