News: OIG audit results in call for CMS to strengthen improper payment safeguards

A recent audit conducted by the Office of Inspector General (OIG) sought to identify potential vulnerabilities in the Medicare program which could be contributing to improper payments for virtual check-in and e-visit services.

Virtual check-in services are intended for patients with an established relationship with the provider, and cannot be related to an evaluation and management visit (E/M) visit, or lead to an E/M visit within the following 24 hours (or soonest available appointment).

E-visits must be initiated by enrollees through online patient portals. These services can occur over a seven-day period, but they must be distinct from other E/M services during that timeframe. CMS first authorized Part B payment for these services in the 2019 and 2020 Medicare Physician Fee Schedule final rules.

The audit covered nearly $24.2 million in Medicare payments for over 1.9 million virtual check-in and e-visit claim lines with dates of services between January 1, 2029, and December 31, 2022. The OIG focused on claims with a higher potential for noncompliance, including the following:

• Virtual check-ins billed within seven days before or 24 hours after an E/M visit for the same beneficiary and diagnosis
• E-visits billed within seven days of another e-visit for the same beneficiary and diagnosis

Through the audit, the OIG estimated that CMS made 173,287 improper payments, totaling in in $1,964,125 for virtual check-in services during the audit period. Each of these improper payments had an associated E/M service claim line—120,316 of which were billed with an E/M modifier.

Nearly 31,000 of the E/M claim lines were billed with modifier -25, which is used to report a significant, separately identifiable E/M service. In these cases, CMS may have made approximately $337,000 in improper payments because the virtual check-in services should have been covered as part of the originating E/M service, not billed separately.

The OIG also found 10,237 potentially improper payments totaling $298,200 for e-visit services. If these e-visits were billed for the treatment of the same medical condition, they should have been billed using a single, higher-level code reflecting the cumulative interaction time over the seven days, rather than as multiple services.

The report identified the lack of system edits to detect non-compliant payments for communication technology-based services as one of the key vulnerabilities. The office recommended that CMS develop pre-payment edits to identify the following:

• Virtual check-ins that occur within seven days after or 24 hours prior to an E/M service and billed with the same diagnosis code
• E-visits that are billed separately with the same diagnosis code but should be billed only within seven days

The OIG also urged CMS to develop post-payment edits, strengthen code descriptions for virtual check-ins, and enhance provider education efforts. Revenue integrity professionals should review the findings to ensure their organization is incompliance with Medicare billing and coding requirements for these services.

Editor’s note: To read the full report, click here. to read additional coverage from NAHRI, click here.