Protect Your Practice: Mitigating the Risks of Medicare Fraud and Abuse with an In-House CCM Program

A healthcare system executive recently confided that the primary reason that they did not decide to self-administer Medicare’s Chronic Care Management program is that the risks of fraud and abuse were too high. 

Having consulted with a client immediately after they paid tens of millions of dollars for an innocent “fraud and abuse” mistake, I began to consider the many fraud and abuse exposures that exist for an organization trying to do CCM on its own. When a practice, hospital, or health system decides to bring CCM in-house, it’s important to highlight and consider the significant risks they may face.

Enrollment

Even before an organization begins to serve patients, the enrollment process poses significant fraud and abuse exposures. Some organizations rely on practitioners to enroll patients in the program. Let’s face it, how much do practitioners know about Medicare and the different plans that exist? What do they know about associated co-pays, deductibles, etc.?

Some organizations focus enrollment solely on Medicare recipients who don’t have deductibles or coinsurance. This kind of selective enrollment is unethical, as cherry-picking advantageous patients not only financially benefits the provider but defeats the point of value-based care. 

Enrollment requires consent. How is this documented? Is it written, electronic, or recorded? Some CCM providers enroll 100% of all eligible patients. Unless the provider has received verbal or written consent from each patient, this is illegal.

Some providers simply state that they will not worry about collecting deductibles and coinsurance, a slippery slope scenario that could lead to serious scrutiny. 

There are eligibility requirements for CCM mandated by CMS. For example, the patient must have two or more chronic conditions and must have been seen by a provider within the last twelve months. Does every enrolled patient in your organization meet these criteria? What processes and procedures are in place to ensure adherence to CMS guidelines?

Outgoing Calls

The first big issue healthcare organizations may face when conducting CCM services is the 20-minute rule. In order to bill for CCM under the billing code CPT 99490 or G0511, there must be 20 minutes of documented time, meaningfully spent on behalf of the patient each month. Most monthly patient calls last only eight minutes or less. How sound is your documentation and timekeeping? How will you track time spent on activities outside of the phone call? Are you recording the phone call for audit purposes?

What percentage of the enrolled patients is the organization billing for each month? Is every file documented sufficiently? If 100% of patients are being billed, is there sufficient documented work to justify the fees?

If codes that require additional minutes are being used, is the provider appropriately engaged and is time documented properly in the medical record?

Incoming Calls

Does the organization staff a clinical support center for patient calls, 24 hours a day, seven days a week, 365 days a year? How fast can these calls be transferred and escalated to an appropriate provider? If the patient leaves a voicemail, how fast is it returned? 

Billing

Nothing can upend a Chronic Care Management program faster than a billing department. An organization’s billers typically already have their hands full, so dropping hundreds or thousands of new billings on them each month can wreak havoc on the department. Such a large increase in volume is not only overwhelming but can result in mistakes. Individually, these are small billings that may become a low priority.

Summary

Before self-administering a CCM program, consider the issues that surround fraud and abuse. Ask the necessary questions to make sure all bases are covered to avoid potential risk. If there is any hesitancy or inability to address the questions at hand, consider the resources of an experienced CCM partner that specializes in running a compliant, full-service CCM program for you.