OIG urges CMS to strengthen safeguards for virtual check-in, e-visit payments

The Office of Inspector General (OIG) recently conducted an audit to identify potential vulnerabilities in the Medicare program that 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. The check-in cannot be related to an evaluation and management (E/M) visit within the previous seven days or lead to an E/M visit within the following 24 hours (or soonest appointment available). 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, 2019, 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

The OIG determined that CMS made 173,287 potentially improper payments totaling $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.

Notably, 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 remaining E/M claim lines included telehealth modifiers -95 and -GT, suggesting that the services were duplicative in nature. In these cases, only one service should have been reimbursed.

The OIG also identified 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, according to the report.

One of the key vulnerabilities discussed in the report is the lack of system edits to detect non-compliant payments for communication technology-based services. The OIG 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 in compliance with Medicare billing and coding requirements for these services.