Managing Chronic Conditions with RPM and CCM
Chronic conditions, such as diabetes, heart disease, asthma, and COPD, affect a wide segment of the population, and the resulting health problems comprise a large portion of healthcare spending. Care management programs (CMP) and remote monitoring programs (RMP) are designed to help monitor, manage, and treat chronic conditions before they develop into more serious problems. These programs not only have the potential to improve outcomes for patients, but also can reduce spending on expensive healthcare that is required when chronic conditions go unmanaged.
What Are Remote Patient Monitoring and Chronic Care Management?
Two such programs are Remote Patient Monitoring (RPM) and Chronic Care Management (CCM). For RPM, patients who are eligible for the program are provided monitoring devices, such as a glucose monitor for diabetes or a blood pressure monitor for hypertension. The devices send readings to the patient’s healthcare provider, who can be alerted to changes in a patient’s condition and treat or manage the patient’s condition. CCM services are for patients with two or more chronic conditions who can benefit from the coordination of care among different providers. Both RPM and CCM allow providers to bill for some time spent monitoring and managing a patient’s chronic conditions.
How Fraud Occurs in Remote Monitoring Programs
While these programs can be highly effective when done correctly, they are subject to abuse, which can manifest in a number of ways and result in the submission of false claims in violation of the False Claims Act. Medicare often lacks the information necessary to evaluate whether these programs are being abused. See HHS Office of Inspector General, Additional Oversight of Remote Patient Monitoring in Medicare is Needed, Sept. 2024. Whistleblowers with knowledge of abusive practices can be critical to ensuring the integrity of these programs.
Common Types of Fraud in RPM and CCM
Some of the ways in which these remote monitoring programs are abused include:
Ineligible Patients Enrolled in the Program
The RPM and CCM programs have threshold requirements for eligibility, including patient consent, the existence of conditions that require monitoring, and the service must be medically reasonable and necessary.
Failure to Meet Billing Requirements
Both RPM and CCM have time-based billing codes with threshold requirements for billing services, including the existence of two-way interactive communication. To bill for RPM services, the patient must have readings on at least 16 days in a month. Providers may not bill for monitoring or managing a patient’s conditions until they and their staff have spent a specified minimum time on the patient over the course of the month.
Lack of Supervision Over Third-Party Providers
In some instances, third parties may perform the RPM or CCM monitoring services under a physician’s supervision. Physicians who submit bills are responsible for ensuring the services were provided as represented and comply with other laws, including the Anti-Kickback Statute.
How Whistleblowers Can Report RPM & CCM Fraud
If you are aware of fraud in remote monitoring programs and want to know how you can stop the fraud, protect your job, and receive a reward, consider discussing your case at no cost with the whistleblower attorneys at Phillips & Cohen. The firm has a substantial track record of protecting whistleblowers and winning financial awards for them. Keep in mind that timing is important in whistleblower cases.