COMPLIANCE CORNER: Remote Patient Monitoring Faces Increased Scrutiny Following OIG Recommendations

KAITLYN DELBENE
Wachler & Associates, PC

The Office of Inspector General recently issued a report recommending increased oversight following a data analysis of Medicare fee-for-service claims for remote patient monitoring services. Providers should be aware of possible increased scrutiny by CMS, including audits and new proposed coverage criteria.

What Is Remote Patient Monitoring?

Remote patient monitoring (“RPM,” also at times referred to as remote physiologic monitoring) is the collection and transmission of health data in a patient’s home that providers use to remotely monitor a patient’s health status and manage a patient’s condition. To qualify as RPM, the monitoring device must automatically transmit data to the patient’s provider. The provider is then able to review the data, make decisions about the patient’s treatment, and communicate with the patient to discuss any recommendations, such as medication adjustments.

A common example of RPM is the use of a connected blood pressure cuff to regularly collect blood pressure readings in order for a provider to monitor a patient with hypertension. Medicare covers RPM for both chronic and acute conditions, but OIG found that the vast majority of patients are receiving RPM for chronic conditions. In the data reviewed by the OIG, more than half of the patients receiving RPM received it for hypertension. Other common conditions were diabetes with and without complications, followed by sleep-wake disorders.

OIG noted in its report that the use of RPM increased dramatically from 2019 to 2022: The number of patients receiving RPM was 10 times higher in 2022, and total Medicare payments for RPM were over 20 times higher. OIG also observed that RPM is likely to continue to grow, given that over 60% of all Medicare enrollees have hypertension, yet a very small fraction of these enrollees currently receive RPM.

Medicare Coverage for Remote Patient Monitoring

Beginning in 2018, Medicare began making separate payment for certain RPM services. CMS made certain clarifications to its RPM rules following the end of the COVID-19 public health emergency, and its current payment policies for RPM services are contained in the 2021 Physician Fee Schedule final rule. For example, CMS clarified in the final rule that there must be an established patient-physician relationship for RPM services to be furnished, and that 16 days of data each 30 days must be collected and transmitted to meet the requirements for billing the CPT codes for device setup and supply to the patient. In conjunction with applicable coding requirements, the 2021 final rule is the only reimbursement policy issued by CMS for these services.

OIG Recommendations and Potential Ramifications for Medicare Providers

In its report, the OIG made several recommendations to CMS generally aimed at increasing oversight of RPM services. CMS concurred with or stated that it would take into consideration all of OIG’s recommendations, and providers can expect to see increased activity in this area, including Medicare audits, new billing guidance, and possibly new proposed criteria for Medicare coverage of RPM services.

Regarding guidance that might be provided by CMS, OIG recommended generally that CMS conduct provider education about billing of RPM services, but also made some more specific recommendations. First, OIG recommended that CMS should require RPM to be ordered and that information about the ordering provider be included on claims and encounter data for RPM. This recommendation would mark a substantial change and would require providers to make significant adjustments to their RPM processes and documentation. Second, OIG recommended that CMS “develop methods to identify what health data are being monitored.” CMS indicated that it would take both of these recommendations into consideration but noted that each could require notice and comment rulemaking before implementation. Providers should be on the lookout for any proposed national or local coverage determinations and should utilize the comment period to provide input to CMS on any proposals, including the possibility of requiring a provider order for RPM services.

From an audit perspective, any practice routinely using RPM for its patients or with a high proportion of its Medicare billing coming from RPM claims should be prepared for the possibility of an audit, including by a CMS Unified Program Integrity Contractor. Notably, OIG recommended that CMS “identify and monitor companies that specialize in remote patient monitoring.” CMS indicated that as part of its program integrity strategy it has already developed ways “to assist with identifying” RPM providers. In light of the increasing scrutiny of these services, current RPM providers should make sure they are aware of the applicable requirements for billing RPM services and identify resources for confronting an audit if needed.

Katy DelBene is an attorney at Wachler & Associates, PC. Ms. DelBene practices in all areas of healthcare law, representing healthcare providers and suppliers in the defense of Medicare, Medicaid, and third-party payor audits, as well as a broad range of health professional and facility licensing and regulatory compliance matters.