CMS Could Strengthen Medicare Program Safeguards To Prevent and Detect Potentially Improper Payments for Virtual Check-in and E-visit Services

Report Materials

• Full Report (PDF, 1.8 MB)
• Report Highlights (PDF, 348.4 KB)

Why OIG Did This Audit

• CMS has sought to improve access to virtual care by introducing communication technology-based services, such as virtual check-in services and electronic visit services (e-visits). One of the benefits of virtual care is the ability to provide services to Medicare enrollees when access to in-person care is limited.
• We conducted this audit to determine whether there are vulnerabilities that might result in improper payments for virtual care services and opportunities to reduce the risk of improper payments.

What OIG Found

CMS paid providers for virtual check-in and e-visit services during our audit period that may not have complied with Medicare requirements. Specifically:

• CMS made $1,964,125 in potential improper payments for 173,287 virtual check-in services that occurred within 7 days after or 24 hours (1 day) prior to an evaluation and management (E/M) service having the same diagnosis code for the same enrollee. Of these, 120,316 E/M services were also billed and paid with an unnecessary modifier.
• CMS made $298,200 in potential improper payments for 10,237 e-visit services because the services were provided within 7 days of another e-visit having the same diagnosis code for the same enrollee.

Medicare made potentially unallowable payments to providers for virtual check-ins and e-visit services because CMS and Medicare Administrative Contractors did not have system edits in place to detect certain payments at risk for noncompliance; nor did CMS educate providers on the proper billing requirements for virtual check-in and e-visit services.

What OIG Recommends

We made three recommendations to CMS, including that it develop system edits for billing communication technology-based services that could have saved the Medicare program up to $2.3 million during our audit period, strengthen the Healthcare Common Procedure Coding System code descriptions for virtual check-ins in the Physician Fee Schedule, and further educate providers on the proper billing requirements for virtual and e-visit services. The full recommendations are in the report.

CMS concurred with our first and third recommendations and described corrective actions it planned to take, or has already taken, to address the recommendations. CMS did not concur with our second recommendation.