OIG: CMS paid millions in improper virtual care payments

CMS made inappropriate payments, totaling $2.2 million, for virtual care services between 2019 and 2022, according to a new audit report by the HHS Office of Inspector General.

For the audit, the OIG assessed CMS payments for virtual care services, including virtual check-in and e-visit services. Virtual check-in services allow Medicare enrollees with established provider relationships to briefly communicate with their care teams via audio or video technology. E-visits enable Medicare enrollees to remotely communicate with their providers via online patient portals.

The audit revealed 183,524 potentially improper payments totaling over $2 million from $12 million in Medicare payments for 1.3 million virtual check-in claim lines and $11 million for 600,235 e-visit claim lines between Jan. 1, 2019, and Dec. 31, 2022.

CMS paid $1.9 million for virtual check-in services that occurred on the day before or within the seven days after a medical service for the same enrollee using the same diagnosis code. Virtual check-in services cannot originate from a related medical visit in the prior seven days, and they cannot result in a medical service or procedure within the following 24 hours. The agency also paid $298,200 for e-visit services provided within seven days of another e-visit having the same diagnosis code for the same enrollee, the audit found. E-visit communications are restricted to a seven-day period.

The OIG determined that the improper payments resulted from a lack of system edits to detect payments at risk for noncompliance. CMS also did not educate providers on the proper billing requirements for virtual check-in and e-visit services.

The agency made several recommendations to CMS to prevent improper payments in the future, including that CMS develop system edits for virtual care billing. These should include edits to identify payments for further review and to identify and reject claims when virtual check-in and medical services are billed on the same claim.

OIG also recommended that CMS strengthen and clarify the Healthcare Common Procedure Coding System code descriptions for virtual check-ins in the physician fee schedule and enhance provider education regarding virtual check-in and e-visit billing requirements.

Though it disagreed with the HCPCS code description recommendation, CMS agreed to the other two, stating that it planned to take, or has already taken, corrective actions.

This is not the first time the OIG has sought to determine if CMS has made improper payments for virtual care services. Past audits have found that though providers met Medicare requirements when billing for most telehealth-based evaluation and management (E/M) services, CMS did provided excessive telehealth reimbursement for some psychotherapy services in 2020. Additionally, the OIG indicated a need for new measures to monitor billing for remote patient monitoring services following the rise in Medicare RPM payments.  

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.