Last month, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released a new report regarding remote patient monitoring (RPM), which describes existing federal coverage policies and recent utilization rates, as well as recommending additional oversight of the telehealth modality’s use within the Medicare program. In particular, OIG’s review sought to understand how RPM, which is the collection and transmission of health data in a patient’s home to assist providers in managing a patient’s condition, is being used by Medicare patients and billed by Medicare providers. OIG found a dramatic increase in RPM use over the past few years and made a number of recommendations to ensure sufficient oversight and billing of RPM services going forward.
OIG provided a brief history of Medicare RPM coverage and rules to provide context for its findings, mentioning how federal coverage first began for the modality, which Medicare refers to as remote physiologic monitoring, in 2018. Medicare also doesn’t consider RPM to be telehealth, rather it falls under a completely separate policy umbrella (see more information on Medicare RPM and Medicare Communication Technology-Based Services [CTBS] on CCHP’s website). Additional RPM coverage and billing rules include:
- Medicare covers RPM for any type of physiologic data collection using a Food and Drug Administration (FDA) approved medical device for chronic and acute conditions that require monitoring
- Providers bill Medicare using a specific set of procedure codes (Current Procedural Terminology [CPT] codes: 99091, 99453, 99454, 99457, and 99458) that represent three main components of the monitoring: 1) education and setup, 2) device supply, and 3) treatment management
- Health data must be collected and transmitted at least for 16 days every 30 days
- Medicare pays for each component separately and at the same rate
- There is no limit on the length of time an enrollee can be monitored
- “Incident to” billing is allowed and both non-clinical (e.g., office staff) and clinical staff (e.g., a registered nurse) can deliver remote patient monitoring education and device supply, while only clinical staff can deliver treatment management
Given that RPM coverage began in 2018, it is unsurprising that RPM use increased substantially over the following years (which included the COVID-19 pandemic as well). OIG’s report found that the number of Medicare enrollees receiving RPM was more than 10 times higher in 2022 than in 2019, increasing from 55,000 in 2019 to 570,000 in 2022. The increase in traditional Medicare enrollees utilizing RPM was 9 times higher, while the increase in Medicare Advantage was found to be 14 times higher in 2022, in comparison to 2019. Additionally, OIG reported that Medicare payments were over 20 times higher in 2022 than in 2019. OIG attributes the higher payment amounts to both the increase in the number of enrollees using RPM, as well as the average payment per enrollee, which were found to have doubled by 2022. While patients on average used RPM for less than 3 months in 2019, in 2022 enrollees were receiving RPM for an average of more than 5 months. The number of patients receiving RPM long-term – or over 9 months – also increased, with only 5 percent receiving long-term RPM in 2019 and 25 percent receiving long-term RPM in 2022.
Other findings from the OIG RPM report include:
- Most Medicare enrollees received RPM to treat chronic conditions (94%)
- More than half of enrollees received RPM to monitor hypertension, followed by diabetes
- Black enrollees and those dually eligible for Medicare and Medicaid received RPM at higher rates
An additional finding reported by OIG in its review of billing data was that around 43 percent of enrollees who received RPM did not seem to receive all three monitoring components (education and setup, device supply, and treatment management). While Medicare doesn’t require billing for each component, the lack of claims or encounter data confirming patients are receiving all necessary components left OIG concerned whether RPM is being used as intended. For instance, these enrollees appeared to not receive education about how to use and set-up their device, didn’t receive a device, or didn’t transmit their health data as required – all of which OIG states are critical to ensuring the proper use of RPM. Additionally, some enrollees didn’t appear to receive treatment management, meaning they may not have received the true benefits of RPM, or that it may have been unnecessary. OIG flags these issues in relation to its previous telefraud alerts (see OIG RPM Consumer Alert and CCHP OIG Fraud Alert article [dated July 26, 2022] for more information), highlighting its past concerns with unscrupulous companies utilizing telemarketing tactics to sign up Medicare enrollees for unnecessary services they typically never receive. Again, these telefraud alerts are not specific to the modality in which the services are being provided, but rather specific to the activities of the company potentially billing fraudulently (see CCHP Telefraud vs. Telehealth [dated Oct. 5, 2021] and QFRs Provide Insight on OIG Telehealth Perspective [dated Dec. 7, 2021] articles for additional background on the distinctions between telehealth and telefraud).
To address these concerns in relation to RPM, OIG makes a number of recommendations to increase the types of information Medicare receives to ensure more sufficient oversight. For instance, Medicare currently doesn’t receive information on the type of data being collected (i.e. blood pressure) and devices (i.e. blood pressure cuff) being used, nor does it have a way to identify companies specializing in RPM services. In some instances, Medicare is not receiving enough information to ensure RPM is being used to treat eligible conditions, and for 44 percent of enrollees, Medicare didn’t receive any information on the provider ordering RPM. OIG’s recommendations include:
- Institute safeguards including periodic analysis/follow-up to identify providers frequently billing for enrollees not receiving all three RPM components or without specific diagnosis codes
- Require RPM to be ordered by a physician or other qualified provider and that identifying provider information be included on claims/encounter data, similar to existing requirements for ordering durable medical equipment (DME) and other laboratory and imaging services
- Develop more specific RPM codes that specify types of data collected and device used
- Conduct provider education about RPM billing that summarize guidelines and safeguards
- Identify and monitor companies specializing in RPM, such as developing a new provider enrollment classification and ensuring appropriate billing
- Improving incident-to billing transparency by requiring a modifier and additional provider identification (previously a past OIG recommendation)
The Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program, concurred with or agreed to take into consideration all of OIG’s recommendations. OIG highlighted in its report that its findings are additionally important when considering that the use, and need, for RPM is likely to increase given that more than 60 percent of Medicare enrollees have hypertension – the most frequent chronic condition associated with current RPM use – however, only a small amount of those particular enrollees were found to already be receiving RPM.
While Medicare doesn’t technically consider RPM to be telehealth, reports evaluating the use of remote care generally are important to policymakers considering telehealth policy needs at the federal level. Additionally, state Medicaid programs, whether they consider RPM to formally be telehealth or not, often do incorporate the same Medicare codes and guidelines into their RPM coverage rules, if such policies exist – see more information by state on CCHP’s Medicaid RPM page. A Medicaid report from earlier this year by Health Affairs had similar RPM findings to those documented by OIG as well. For instance, RPM use increased by more 1,300 percent from 2019 to 2021 among the Medicaid population, particularly for patients with hypertension and diabetes. In addition, Health Affairs assessed the variability of RPM use in context with state Medicaid coverage policies, finding that while only 34 states as of March 2023 had explicitly documented RPM reimbursement policies, providers from all states except Vermont billed RPM codes on billing claims in 2021. The rate of RPM use in 2021, however, was more than 30% higher in states with documented reimbursement policies, showcasing the importance of provider education and outreach and clear coverage policies in ensuring appropriate remote care accessibility. As state and federal policymakers consider these findings, it is vital that reoccurring themes be identified and that concerns be placed in context with any oversight measures planned, as well as the benefits and need for these modalities to ensure additional policies properly promote access to necessary medical care.
For more information on the Medicare RPM study, please view the OIG report in its entirety. The Medicaid RPM study can be accessed on the Health Affairs website.
Potential DEA Temporary Rules Extension for Prescribing Controlled Substances via Telehealth
Politico recently reported (subscription required) that the U.S. Drug Enforcement Administration (DEA) is indicating another extension is likely for the temporary federal flexibilities allowing providers to prescribe controlled substances via telehealth without an in-person visit. The previous policy extension is set to expire at the end of 2024. The new final rule titled, “Third Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications,” reportedly reached the White House for review earlier this month. This will be the second time that the DEA attempted to draft permanent policy on the subject but due to various concerns and stakeholder push back, the DEA appears to be moving forward with another additional extension instead. Earlier this year, the DEA crafted a proposal (that wasn’t made public) allegedly containing substantial prescribing limitations, although it stalled at the White House review stage due to purported concerns from the U.S. Department of Health and Human Services (HHS). Last year, prior to this latest attempt, the DEA publicly released another proposed permanent policy that received nearly 40,000 public comments, leading to the currently in effect policy extension. CCHP has covered the issue extensively and produced a timeline related to the DEA telehealth prescribing policy history – see the latest CCHP DEA articles for more information: DEA Rules (dated Oct. 8, 2024), Updates Regarding Upcoming DEA Rules (dated Sept. 10, 2024), and Regulatory Crossroads (dated July 16, 2024). It is unclear how long the latest DEA telehealth prescribing extension would be for, but CCHP will continue to update readers as additional developments occur. |
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