An audit found $2.3M in improper Medicare virtual-care payments
Summary
CMS built virtual check-ins and e-visits so Medicare patients could reach a doctor without an office visit, then built no automated check to catch a virtual check-in and an office visit billed days apart for the same diagnosis. A federal audit found $2,262,325 in potentially improper payments -- 9.4% of the $24.15 million CMS paid for these services from 2019 through 2022 -- and traced $337,033 of that to a routine billing modifier that let claims bypass the one automated check Medicare did have. CMS has since built the missing system edits, but rejected the audit's recommendation to clarify the ambiguous standard -- 'related or same medical condition' -- that led providers to misbill in the first place.
Two benefits built to save a trip, one gap left open
CMS's own guidance⧉ is specific about the line a virtual check-in isn't supposed to cross: the service must be unrelated to any office visit -- what Medicare calls an evaluation and management, or E/M, service -- in the 7 days before it, and it mustn't lead to one in the 24 hours after, billed under code G2012 for a brief 5-to-10-minute discussion. E-visits work on similar logic: a patient messages a provider through an online portal, and the provider bills once for the cumulative time spent replying over a rolling 7-day window, not once per message. OIG's audit⧉ covered $24,151,327 paid across more than 1.9 million virtual check-in and e-visit claim lines for dates of service from January 2019 through December 2022.
View data as table
| Virtual check-in dollars audited | 12,479,542 |
|---|---|
| Virtual check-in dollars found improper | 1,964,125 |
| E-visit dollars audited | 11,671,785 |
| E-visit dollars found improper | 298,200 |
Where the money went wrong
Auditors flagged $1,964,125 across 173,287 virtual check-in claims -- involving 66,899 enrollees -- billed within that 7-day/24-hour window of an E/M visit using the same diagnosis code⧉, which should have folded the check-in into the office visit rather than billing it separately. In one example cites, a provider billed $42.52 for an office visit for hyperlipidemia, then billed two more virtual check-ins with the identical diagnosis code the following business days for $10.43 each -- a $20.86 overpayment⧉ for what should have been a single visit. E-visits showed the same pattern in miniature: $298,200 across 10,237 claims, tied to 6,809 enrollees, billed as separate e-visits within a 7-day window instead of one claim at the cumulative time spent.
A modifier let claims skip the one check that existed
had exactly one automated safeguard in its claims-processing system, and a routine two-character billing code -- a "modifier," appended to a claim to give Medicare extra context -- could turn it off. Of the 120,316 evaluation-and-management claims tied to a flagged virtual check-in, 30,743 carried modifier 25⧉ -- a code meant to flag a genuinely separate same-day service -- which let the claim bypass 's prepayment edit entirely and pushed $337,033 of the improper total through unblocked. The remaining 89,573 carried telehealth modifiers 95 or GT, which don't change the payment but flag a video-delivered service -- often, found, for the exact same diagnosis a virtual check-in had already been billed for days earlier.
View data as table
| Modifier 25 (bypasses the prepayment edit) | 30,743 |
|---|---|
| Telehealth modifiers 95/GT (no bypass) | 89,573 |
CMS fixed the checks. It rejected fixing the words.
OIG made three recommendations⧉: build the missing system edits (potentially saving up to $2.3 million over the audit period), rewrite the ambiguous billing-code language -- "related or same medical condition," "soonest available appointment" -- that providers were misreading, and educate providers on the rules. agreed to the first and third, and says it has since built the edits and continues provider education. It rejected the second, arguing the fix belongs in non-binding subregulatory guidance rather than the code descriptions themselves; maintains the recommendation, noting that kind of guidance "is not legally binding and cannot be enforced" -- meaning the ambiguity that caused the misbilling remains uncorrected in the one document providers actually bill against.
The takeaway
- built the payment system with no way to catch double-billing. Neither nor its Medicare Administrative Contractors had an automated edit to flag a virtual check-in and an E/M visit billed days apart for the same diagnosis -- the gap says drove most of the $2.26 million finding.
- A routine modifier neutralized the one check that did exist. Modifier 25, meant to flag a genuinely separate service, let 30,743 E/M claims bypass 's prepayment edit and pushed $337,033 of improper payments through unblocked.
- fixed the system, not the rule that confused providers. It built the missing edits and expanded provider education, but rejected 's recommendation to clarify the ambiguous billing language in the Physician Fee Schedule itself, leaving that language open to the same misreading going forward.
's finding rests on matching diagnosis codes and dates across claims data, not a review of medical records -- the audit could not determine with certainty that any individual claim was unallowable, only that it was vulnerable to being improperly paid under 's own rules; did not contact the providers involved. As of January 1, 2025, HCPCS code G2012 was replaced by CPT code 98016 with an identical descriptor, after this audit's period ended. The $2.3 million 's new system edits could save is 's estimate of what the audit period's own flagged payments would have prevented, not a national or ongoing savings projection.
Sources(2) ▾
- HHS Office of Inspector General (OIG), CMS Could Strengthen Medicare Program Safeguards To Prevent and Detect Potentially Improper Payments for Virtual Check-in and E-visit Services (Report A-05-23-00001) (2026-04-23) — A claims-data-analytics audit of Medicare Part B virtual check-in and e-visit payments, dates of service January 2019 through December 2022, including 's formal written response and 's reply. Fetched directly and converted with pdftotext -layout. oig.hhs.gov · original document
- Centers for Medicare & Medicaid Services (CMS), Medicare Telemedicine Health Care Provider Fact Sheet (2020-03-17) — 's own provider-facing description of virtual check-in and e-visit billing rules -- the standard 's audit measured claims against, including the exact HCPCS G2012 code descriptor and the 7-day/24-hour timing rule. cms.gov · original document
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Medicare pays doctors for two kinds of virtual contact that fall short of a full office visit: a "virtual check-in" -- a brief phone or video message a patient sends when unsure whether an appointment is needed -- and an "e-visit" -- a message exchanged over a patient portal across several days. The Centers for Medicare & Medicaid Services (CMS)⧉, the federal agency that runs Medicare, built both benefits so patients could reach a doctor without traveling to an office. An HHS Office of Inspector General audit⧉ -- 's independent watchdog -- found paid $2,262,325 for 183,524 of these claims, from 2019 through 2022, that didn't meet the agency's own billing rules, because no automated check existed to catch them.