How to Provide Additional Oversight to Ensure That Remote Patient Monitoring for People With Diabetes is Being Used and Billed Appropriately

Abstract

An Office of the Inspector General (OIG) report on September 19, 2024, highlighted the need for additional oversight of remote patient monitoring (RPM), which is covered by Medicare. OIG noted that Medicare claims frequently lack crucial information that would facilitate proper oversight. While Medicare has published guidelines for reimbursement according to RPM billing codes, greater clarity is needed to avoid inadvertent improper billing practices. In this article, we discuss potential revisions in Medicare policies for documenting RPM services. Such revisions will result in enhanced accountability and traceability of RPM services and reduce the potential for improper billing. Adherence to clear billing guidelines will ensure appropriate allocation of funds and safeguards the future of RPM services for Medicare beneficiaries who genuinely need them.

Introduction

Discrepancies in billing practices and improper use of RPM services threaten to undermine the significant potential of this vital health care tool for Medicare beneficiaries. The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) report on September 24, 2024, reveals concerning trends, in that 43% of Medicare enrollees who received RPM services in 2022 did not receive at least one of the three necessary components of the service. ¹ This inconsistency raises serious questions about whether RPM services are being used as intended and billed appropriately. With RPM becoming a larger financial cost center—Medicare payments surged from $15 to $300 million between 2019 and 2022—concerns have emerged that inadvertent billing errors or gray areas in billing practices could lead Medicare to reconsider or reduce its coverage of these services to mitigate potential misuse in the future. To address these concerns and preserve access to RPM for patients who truly need it, health care professionals must take immediate action to ensure strict compliance with Medicare’s reimbursement policies and implement rigorous documentation practices. we can safeguard the future coverage of RPM services for Medicare beneficiaries. We call upon Centers for Medicare & Medicaid Services (CMS) to establish three types of policies to combat inappropriate billing practices so that their funds intended for RPM can be spent appropriately where they are truly needed so these funds are not wasted. We recommend (1) offering professional education about proper RPM services and billing practices, (2) providing clear information about RPM coverage, and (3) adopting more stringent penalties to improper billing practices.

What Coverage Does Medicare Provide for RPM?

Remote patient monitoring (RPM) is an indispensable tool in modern health care that should be more widely adopted and well-regulated to maximize its potential in chronic disease management, particularly for chronic conditions benefiting from intensive monitoring, like diabetes. Medicare’s decision to cover RPM services in 2019 marked a significant step toward recognizing RPM’s value in expanding patient care beyond traditional clinical settings. ² The three primary components of RPM—monitoring devices, patient education, and ongoing treatment management—provide a robust framework for tracking and managing chronic conditions. RPM for home care, compared with conventional in-clinic visits, offers unprecedented flexibility for both patients and professionals. ¹ CMS did not issue guidance on the proper utilization of these codes for the first two years following their implementation in 2019. The lack of early guidance, combined with the novelty of the codes, makes 2019 a pivotal reference point for understanding the evolution of RPM code utilization. Between 2019 and 2022, the number of Medicare beneficiaries utilizing RPM services increased significantly, growing nearly tenfold from approximately 55,000 patients in 2019 to 570,000 by 2022. ³ Concurrently, the cost per remotely monitored patient more than doubled, contributing to a significant rise in Medicare’s total spending on RPM from $15 million in 2019 to $311 million by 2022. ³ The expansion of RPM coverage to include both chronic and acute conditions has further broadened its use, making it an invaluable tool in disease management across many patient populations.

For people with diabetes (PwD), RPM offers major benefits by enabling real-time tracking of blood glucose levels and other vital metrics, allowing for timely interventions that can prevent complications and reduce hospitalizations. ⁴ Blood glucose monitoring (BGM) and continuous glucose monitoring (CGM) systems are examples of medical devices that can transmit critical data directly to health care professionals by way of the electronic health record or an accompanying app. These monitoring devices, often paired with smartphones or other internet-connected platforms, allow patients to seamlessly share their glucose readings, insulin doses, and other relevant health information with their care team. Under Medicare coverage, PwD can benefit from RPM services that include the use of these connected devices. Health care professionals can bill for the initial setup and patient education on using the devices, the monthly supply and data transmission, and the time spent on RPM treatment management. This framework of coverage ensures that patients receive ongoing support and that health care professionals can make timely adjustments to treatment plans based on the wealth of recent and real time data collected.

Medicare’s reimbursement structure for RPM includes three key components ⁵ :

1. A one-time fee for the initial setup and patient education on how to use the device.

2. Ongoing coverage for the use of the device itself, which involves continuous monitoring of data, such as glucose levels or blood pressure, sent directly to the health care professional or care team.

3. Monthly review and interpretation of this data, as well as for the time spent communicating with the patient regarding treatment adjustments.

RPM services are covered under five specific CPT codes, which account for all aspects of RPM (Table 1). These codes cover the entire RPM process, from initial device setup to ongoing data collection, interpretation, and patient communication, reimbursing providers for time spent managing each RPM patient to enhance engagement and personalized care. Of note, CPT code 99091 was introduced in 2002 long before the broader adoption of telehealth and newer RPM CPT codes, and therefore can only be billed by physicians or qualified health care professionals. Its more modern counterparts, CPT codes 99457-99458, are better suited for team-based workflows performed by clinical staff working under supervision, which may be more scalable and cost-effective for clinics. Greater clarity from CMS on the use of the CPT codes, particularly the definition of “interactive communication” for codes 99457-99458, would be beneficial, as it is unclear whether real-time interaction is necessary or whether asynchronous communication methods can fulfill the requirement.

Table 1.

Current Medicare Guidelines for RPM Documentation.

RPM CPT Codes6,7	99453: Initial setup and patient education (one-time) 99454: Data transmission from device to health provider’s systems (once per month) 99457: First 20 minutes of data interpretation and treatment modification. Must include synchronous, interactive communication. Can be billed by physician, QHCP (qualified health care professional), or clinical staff under general supervision of a physician (once per month). 99458: Each additional 20 minutes of RPM treatment management with patient (may be billed after 99457 has been completed per month) 99091: First 30 minutes spent in the collection, analysis, and interpretation of physiological data by physician or QHCP. Cannot be billed by clinical staff. (once per month)
Billing Requirements5,6,a	Face to face visit in the last 12 months RPM is billed monthly Patients need at least 16 days of device readings per 30-day period to bill 99453 and 99454 Only one practitioner can bill RPM per patient in a 30-day period Patient consent must be obtained before providing RPM services RPM must be ordered by a physician or qualified health care professional An RPM device must fit within the FDA’s definition of a medical device The patient must opt-in for the service before the practitioner can order a device All data collection must be HIPAA-compliant 99091 and 99457-99458 cannot be billed concurrently.
Reimbursement8,b	99453: $19.65 (one-time) 99454: $46.83 (monthly) 99457: $48.14 (monthly) 99458: $38.64 (monthly) 99091: $52.71 (monthly)
Best Practices 9	Bill RPM codes monthly, with the date of service as the last day of the month Ensure proper documentation of time spent and services provided RPM can be billed concurrently with chronic care management and other care coordination services Verify coverage and requirements with each payer, as policies may vary across states

a

Flexibilities (under FDA issued enforcement policies) were permitted during the COVID-19 public health emergency in March 2020 that allowed billing for RPM even if only 2 days duration. Those flexibilities ended in May 2023. ¹⁰

b

Using 2024 average Medicare reimbursement rates.

RPM for diabetes has seen significant advancements in recent years, with a variety of devices now available to help patients and health care professionals manage the condition more effectively.

Data aggregation platforms provided by Glooko and Tidepool or platforms linked with their specific blood glucose monitors, CGMs, or insulin delivery devices allow for integration of data from various devices, providing a comprehensive view of a patient’s diabetes management. The iCoDE project is intended to facilitate automatic uploading of CGM data into the electronic health record ¹¹ and the iCoDE2 project is intended to facilitate automatic uploading of insulin dosing data into the electronic health record. ¹²

What Current Problems is Medicare Observing With Their Coverage of RPM?

The current problems Medicare is observing with their coverage of RPM are concerning and could lead to future reduction in reimbursement for RPM services and undermine the intended benefits of this beneficial program. The recent report from the HHS-OIG has exposed important issues that affect health care professionals who prescribe RPM. Failure to deliver all three essential components of RPM as defined by Medicare not only raises questions about the effectiveness of the RPM services, but also suggests potential waste of Medicare resources. ¹ However, we note that health care professionals may be foregoing the treatment/management RPM codes (99457/99458/99091) because of their novelty and lower reimbursement rates, and instead opting to manage patients identified through RPM data review via follow-up evaluation and management (E/M) visits (CPT Codes 9921X). The impact of lack of transparency (which we define as clarity and specificity) by CMS about reimbursement for RPM services leads to (1) inconsistent pricing with associated inequities in access and compensation, (2) difficulty in planning for cost-benefit analyses of service with associated reluctance to invest in an RPM infrastructure without a clear understanding of potential reimbursement, and (3) confusion in billing practices with associated claim denials or underpayment. Lack of transparency about billing requirements could lead to inconsistent payments since the same service might be billed with different codes by different physicians. In addition, lack of transparency in billing practices limits Medicare’s ability to ensure that the RPM services are meeting their requirements. ¹³ Medicare often lacks crucial information about the types of health data being collected, the conditions being monitored, and who ordered the RPM services. ¹

The OIG report suggests that claims should include the ordering provider’s name and clearly indicate the specific device(s) being used for RPM to ensure accurate billing and proper oversight of these services. One key recommendation is to implement methods to better capture the type of data being collected, possibly through the creation of new HCPS codes or modifiers. Some organizations, such as the American College of Physicians (ACP) already suggest using CGM-specific codes (95249, 95250, 95251) instead of standard RPM codes when appropriate. ¹⁴ This approach would provide more clarity about the type of monitoring being conducted and the devices involved. In addition, the OIG has made several recommendations to the CMS, as outlined in Table 2. These recommendations aim to enhance the accountability and traceability of RPM services and reduce the potential for improper billing, ensuring that CMS and auditors can accurately identify who is providing these services and under what circumstances. Concentrating on efforts on promoting transparency and, in turn, accuracy in billing practices, rather than curtailing RPM coverage, would allow Medicare to collaborate more effectively with health care professionals in effectively utilizing RPM services and managing care.

Table 2.

Three OIG Recommendations for CMS to Improve the Transparency of “Incident to” Services.

Under “incident to” billing, CMS allows providers to use their own identification number for remote patient monitoring that was delivered by clinical staff or, in some circumstances, nonclinical staff.

CMS should require the use of a modifier to indicate “incident to” services on Medicare claims and encounters.

In addition, CMS should take steps to allow providers to report the identification number of the staff who delivered the service, when available.

Poor documentation practices by physicians can hamper discovery of billing errors and makes it challenging for Medicare to ensure that RPM services are being used appropriately. Perhaps most concerning is the emergence of companies abusing the system, where patients without medical justification are persuaded to add more devices to their RPM service than they can realistically monitor. The OIG published an alert in 2022 warning practitioners to exercise caution when entering arrangements with purported telemedicine companies who are offering illegal kickbacks for referrals for medically unnecessary services and corrupting the medical decision-making process. The alert included a list of suspicious characteristics related to practitioner arrangements with telemedicine companies which, taken together or separately, could suggest an arrangement that presents a heightened risk of fraud and abuse. ¹⁵ This list is presented in Table 3. These practices not only waste Medicare resources but also potentially put patients at a higher risk of financial distress in the long-term by enrolling them in unnecessary monitoring programs.^15,16

Table 3.

Suspicious Characteristics Related to Practitioner Arrangements With Telemedicine Companies Which, Taken Together or Separately, Could Suggest an Arrangement That Presents a Heightened Risk of Fraud and Abuse. ¹⁵

• The purported patients for whom the Practitioner orders or prescribes items or services were identified or recruited by the Telemedicine Company or a telemarketing company, sales agent, recruiter, call center, health fair, and/or through internet, television, or social media advertising for free or low out-of-pocket cost items or services.

• The Practitioner does not have sufficient contact with or information from the purported patient to meaningfully assess the medical necessity of the items or services ordered or prescribed.

• The Telemedicine Company compensates the Practitioner based on the volume of items or services ordered or prescribed, which may be characterized to the Practitioner as compensation based on the number of purported medical records that the Practitioner reviewed.

• The Telemedicine Company only furnishes items and services to Federal health care program beneficiaries and does not accept insurance from any other payer.

• The Telemedicine Company claims to only furnish items and services to individuals who are not Federal health care program beneficiaries but may in fact bill Federal health care programs.

• The Telemedicine Company only furnishes one product or a single class of products (e.g., durable medical equipment, genetic testing, diabetes supplies, or various prescription creams), potentially restricting a Practitioner’s treating options to a predetermined course of treatment.

• The Telemedicine Company does not expect Practitioners (or another Practitioner) to follow up with purported patients nor does it provide Practitioners with the information required to follow up with purported patients (e.g., the Telemedicine Company does not require Practitioners to discuss genetic testing results with each purported patient).

What Are the Risks if Current Problems Observed by Medicare Aren’t Corrected?

While the OIG report rightfully calls for increased oversight, it is imperative that health care professionals ensure compliance with RPM billing practices before Medicare considers taking or actually takes strict measures that could limit patient access to these life-changing services. The responsibility is on physicians and health care organizations to meticulously document RPM services offered to patients and strictly adhere to Medicare’s reimbursement policies. Failure to do so not only jeopardizes the future of RPM coverage but may also put countless patients under Medicare at risk of losing access to vital care (Table 4).

Table 4.

A Series of If-Then and How PwD May Be Impacted if Current Problems Observed by Medicare Aren’t Corrected.

If	Then	Outcome for PwD
Poor documentation practices	Facilitation of improper or even fraudulent activities	Some patients do not receive the full intended benefits
Inconsistent delivery of RPM services	Missed opportunities for early intervention	More frequent episodes of severe hypo- or hyperglycemia, increasing the risk of complications
Lack of proper oversight by health care professionals	Inadvertent billing errors or gray areas in billing practices could continue to drain Medicare resources	New Medicare policy mandating reduced coverage for legitimate RPM services and requirement for PwD to pay out-of-pocket for essential monitoring devices and services
PwD receive substandard or incomplete RPM services	Erosion of trust in RPM services	Decreased patient engagement essential for effective diabetes management

If the current issues in Medicare’s RPM billing practices persist, then the program may have to limit current benefits offered to its beneficiaries. Health care professionals might underutilize RPM because of the financial and administrative burden, leading to missed opportunities for early intervention in chronic disease management. Patients, especially those in underserved or rural areas, may not experience the potential improvements in health outcomes that RPM promises. In addition, if technological access barriers and privacy concerns persist, then there could be an erosion of trust in RPM systems, ultimately undermining patient engagement and adherence. In the long-term, cutbacks in RPM reimbursement could paradoxically lead to higher health care costs because of complications from poorly managed chronic conditions that might result in preventable hospital admissions.

The AMA’s CPT Editorial Panel has approved new RPM codes (99XX4 and 99XX5), set to take effect in January 2026. ¹⁷ These changes, which include new codes and modified requirements for data collection and monitoring time, are likely to expand RPM accessibility. CMS could use this time from now until January 2026 to review its policies, provide clarity on future Medicare billing practices, and develop educational resources to ensure smooth implementation when the changes come into effect. Table 5 shows five recommendations issued by the OIG to CMS.

Table 5.

Five Recommendations by OIG to CMS to Strengthen Oversight of Remote Patient Monitoring.

1. Implement additional safeguards to ensure that remote patient monitoring is used and billed appropriately in Medicare.

2. Require that remote patient monitoring be ordered and that information about the ordering provider be included on claims and encounter data for remote patient monitoring.

3. Develop methods to identify what health data are being monitored.

4. Conduct provider education about billing of remote patient monitoring.

5. Identify and monitor companies that bill for remote patient monitoring.

A limitation of this analysis is that should CMS invest further resources in more specific billing work on this issue, it is not completely certain that the increased traceability would be acted on, in the setting of competing priorities for billing audits. It may be appropriate for CMS to consider whether the value generated from RPM depends on (1) a recent history of clinical complications, (2) data quality, and (3) the specific portal/product/platform that is being utilized for RPM. If CMS should eventually determine in the future that any of these factors may modulate the clinical value of RPM, then routinely documenting these factors may justify greater or lesser reimbursement for similar services.

How Might an Altered Coverage Policy With Medicare Impact PwD?

The rapid expansion of RPM utilization, with Medicare payments skyrocketing from $15 to $300 million between 2019 and 2022, while indicative of RPM’s potential for managing various conditions, has also exposed the service’s vulnerabilities to discrepancies in billing practices compared with published guidelines. However, an altered Medicare coverage policy in response to abuse that limits access to RPM for PwD could have negative impacts. By increasing administrative burdens, lowering reimbursement rates, and limiting eligibility criteria, fewer health care professionals would likely adopt RPM for diabetes management. PwD would not be able to benefit from more consistent monitoring of glucose levels, blood pressure, and other key metrics, that would otherwise allow for more timely interventions before complications arise. Such a policy shift could lead to more complications, hospitalizations, impaired quality of life, and higher overall health care costs for PwD. If policy adjustments are not carefully considered, then they could exacerbate health disparities by leaving behind vulnerable populations who may already lack access to technology or struggle with its use, as shown in Table 6.

Table 6.

A Series of if-Then and How PwD May Be Impacted by an Altered Policy.

If	Then	Outcome for PwD
Medicare is forced to implement stricter regulations or reduce coverage	Disproportionately affect vulnerable populations	Older adults and/or low-income PwD may have reduced access to essential RPM services
More conservative approach by Medicare in approving new RPM technologies for coverage	Slow adoption of innovative diabetes management tools	PwD may receive coverage for more limited benefits in care and management
Discrepancies in billing practices continue unchecked	Trigger a severe regulatory response that overcompensates	Providers may have a more difficult time providing legitimate RPM services to PwD who could benefit from them
Effective RPM services are limited	Unable to prevent diabetes-related complications through early intervention	Preventable hospitalizations and emergency department may become more common

The value of structured BGM and CGM in diabetes management is well-established.^18,19 For the vast majority of patients with type 2 diabetes who rely on BGM/CGM, RPM services provide a vital link to their health care team, which allows for timely interventions and treatment adjustments, potentially preventing costly complications and improving overall health outcomes. CGMs are an important part of diabetes management. Correcting inappropriate billing practices will probably help to maintain payment for this tool. Ultimately, it is up to CMS to prioritize accurate billing practices for CGMs, although admittedly CMS has a variety of priorities and a limited budget to monitor billing practices for other services.

If Medicare were to significantly restrict or cut back coverage for BGM/CGM under RPM programs in response to the OIG report, then the consequences could disproportionately affect elderly, rural, and low-income patients who already face barriers to accessing care and who can benefit from RPM. Furthermore, imposing additional administrative burdens on health care professionals in an attempt to curb inappropriate billing of RPM services could have unintended consequences, where clinicians might reduce their use of RPM services, exacerbating issues of burnout and potentially reducing the quality of care provided to patients with diabetes.

Conclusions

In conclusion, we recommend that Medicare (1) offer professional education about proper RPM services and billing practices, (2) provide clearer guidelines about RPM coverage, and (3) adopt more stringent penalties to errors in billing. One specific area where clearer guidance from CMS would be welcome pertains to clarifying the extent of which “interactive, synchronous communication” must take place for the proper billing of codes 99457-99458. As it currently stands, the 2021 CMS-issued Final Ruling only states that the time used for these codes “can include time for furnishing care management services as well as for the required interactive communication,” but does not elaborate further. ²⁰ In addition, we call for CMS to provide greater clarity in necessary billing practices, ²¹ considering that some organizations, such as the ACP, has advised that CGM users should be billed under CGM-specific codes (95249, 95250, 95251) rather than general RPM codes. ¹⁴ Finally, we call upon every health care professional involved in RPM to treat proper documentation and billing with the same level of importance as patient-care itself—because, in this case, they are inextricably linked.