HHS-OIG Announces an Audit of Medicare Payments for Chronic Care Management Services and Signals It Remains an Enforcement Priority

On March 16, 2026, the Office of Inspector General for the US Department of Health and Human Services (HHS-OIG) announced an audit of Medicare Part B payments for chronic care management (CCM) services. The audit will specifically examine whether beneficiaries who are receiving CCM services meet the Medicare eligibility requirement that they suffer from multiple chronic conditions. The impetus of the audit, which HHS-OIG expects to complete by 2028, was a substantial increase in CCM claims submitted between 2019 and 2024.

Separate Reimbursement for CCM Services Is Still Relatively New

The Centers for Medicare & Medicaid Services (CMS) began separately reimbursing providers for CCM services under the Medicare Physician Fee Schedule in January 2015. CCM services involve the provision of at least 20 minutes of care management services per month to a beneficiary suffering from two or more chronic conditions. The chronic conditions must be expected to last at least 12 months (or until death of the beneficiary) and place the beneficiary at a significant risk of death, acute exacerbation or decomposition, or function decline. Providers must confirm a patient’s eligibility for CCM services during an initiating visit and obtain his or her consent to receive services before they are billed.

CCM services are typically non-face-to-face and consist of care management services performed outside of traditional patient examination. These activities include reconciling medications, reviewing labs and diagnostic tests, updating care plans, and coordinating with other members of a patient’s care team to ensure that the management of a patient’s multiple chronic conditions is effectively integrated into his or her primary care plan. 

As CMS only recently began reimbursing for CCM services and a majority of the covered activities occur outside of a typical face-to-face patient interaction, Goodwin continues to work to educate government agencies on how these services are administered in practice and the critical role they play in improving patient health outcomes. 

HHS-OIG Has Previously Audited Chronic Care Management Services 

HHS-OIG’s upcoming audit is not the first time the agency has conducted a review of CMS’s payments for CCM services. In a report published in November 2019, the Office of Audit Services found that CMS overpaid hundreds of thousands of dollars in the first two years it reimbursed for CCM services. A follow-up audit published in August 2021 found that CMS reimbursed almost $2 million for ineligible CCM services during 2017 and 2018. HHS-OIG emphasized that CCM services are at a higher risk for overpayment because they are a relatively new category of Medicare-covered services, there are a number of restrictions regarding when and how CCM services can be billed for, and at the time of the audits, CMS lacked sufficient controls to prevent and detect CCM claims that did not comply with federal regulations. 

CCM Services Are a DOJ Enforcement Priority 

Detecting fraud, waste, and abuse in the provision of CCM services is also a current priority for the US Department of Justice (DOJ). In June 2024, the DOJ announced it reached a nearly $15 million settlement agreement to resolve allegations against a company that was the then-highest biller of CCM services. The settlement stemmed from a qui tam complaint alleging that defendants violated the False Claim Act by, among other things, submitting claims for CCM services that were not provided in conformity with Medicare regulations.¹

Takeaway 

The recent activities of HHS-OIG and the DOJ signal that healthcare companies and medical providers can expect a continued focus by government agencies on the provision of and reimbursement for CCM services. This may lead to an increase in audit requests, overpayment determinations, payment suspensions, and investigations by HHS-OIG and the DOJ. Goodwin’s Government Investigations, Enforcement & White Collar Defense lawyers will continue to monitor CCM enforcement developments and the impact they may have on Goodwin’s clients in the healthcare industry.

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1. ^[1] US ex rel. Loscalzo v. Bluestone Physician Services of Florida et al. (Middle District of Florida, 2024). ↩

This informational piece, which may be considered advertising under the ethical rules of certain jurisdictions, is provided on the understanding that it does not constitute the rendering of legal advice or other professional advice by Goodwin or its lawyers. Prior results do not guarantee similar outcomes.