Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part B of A billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

In November 2019, the Office of Inspector General (OIG), published a report titled “Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Management Services” (A-07-17-05101). The OIG noted that CCM services are a relatively new category of Medicare-covered services and have multiple restrictions on when and how they can be billed. In its report, the OIG looked at both physician and facility claims for CCM services. The CMS defines CCM as a physician-provided or physician-directed service; therefore, CMS will pay the outpatient facility for CCM services only when the facility provides these services at the direction of a physician. There is no requirement that CCM services billed by outpatient facility have a corresponding claim billed by a physician; however, because CCM is a physician-directed service, it is reasonable to expect that in most cases a physician would submit a claim for the same service. The OIG reviewed CCM services billed by facilities without a corresponding physician claim and identified approximately $1,162,562 in potential overpayments. CMS tasked the SMRC to review a sample of outpatient facility claims to determine if claims were billed properly.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on CCM facility claims. Noridian completed medical review on a sample of claims related to CCM services. The SMRC conducted reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Provider did not submit additional records requested.
  • Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Incomplete/Insufficient Information
  • Social Security Act (SSA) 1833(e) and the Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(6) require suppliers/providers to provide sufficient information to support that the basic conditions were met for Medicare payment. This is further outlined in Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8.
• Documentation Does Not Support the Claim as Billed
  • Internet-Only Manual Pub 100-08 Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4, Pub 100-04 Medicare Claims Processing Manual, Chapter 23. CCM is a time-based service, in which the medical records would need to support the minimum time associated of the CCM code billed.

References/Resources

• Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits.
• Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
• Social Security Act (SSA) Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• Social Security Act (SSA) Title XVIII, Section 1893 (f)(7)(A)(B)(i-iv). Medicare Integrity Program.
• 42 Code of Federal Regulations (CFR) 410.26(b)(5). Services and supplies incident to a physician’s professional services: Conditions.
• 42 Code of Federal Regulations (CFR) 425.400(c)(1)(iv)(A)(5).
• 42 Code of Federal Regulations (CFR) 424.5(a)(6). Basic Conditions.
• Federal Register. Volume 78. Number 237. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014; Final Rule. Section K. Pages 74414- 74427. Govinfo.gov/content/pkg/FR-2013-12-10/pdf/2013-28696.pdf.
• Federal Register. Volume 79. Number 219. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015; Final Rule. Section H. Pages 67715- 67730. Govinfo.gov/content/pkg/FR-2014-11-13/pdf/2014-26183.pdf.
• Federal Register. Volume 80. Number 54. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015; Corrections. Page 14853. Govinfo.gov/content/pkg/FR-2015-03-20/ pdf/2015-06427.
• Federal Register. Volume 81. Number 220. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Final Rule. Section 4. Pages 80243- 80251 and 80257. Govinfo.gov/content/pkg/FR-2016-11-15/pdf/2016-26668.pdf.
• Federal Register. Volume 83. Number 226. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Final Rule. Section 60. Page 59577. https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf.
• The Centers for Medicare and Medicaid Services (CMS). Frequently Asked Questions about Physician Billing for Chronic Care Management Services. January 1, 2019. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/payment_for_ccm_services_faq2019_updateclean012819.pdf
• The Centers for Medicare and Medicaid Services (CMS). Frequently Asked Questions about Billing Medicare for Chronic Care Management Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Payment-Chronic-Care-Management-Services-FAQs.pdf
• The Centers for Medicare and Medicaid Services (CMS). Medical Learning Network (MLN) ICN MLN909188 July 2019. Chronic Care Management Services.
• Office of Inspector General, A-07-17-05101. Medicare Overpayments for Chronic Care Management Services.

Last Updated Apr 4, 2022