RPM Audits Are Rising: What Healthcare Organizations Need to Know to Stay Compliant

As the adoption of Remote Physiological Monitoring (RPM) and Chronic Care Management (CCM) services accelerates, so too does regulatory scrutiny. In September 2024, the Office of Inspector General (OIG) issued a report calling for increased oversight of RPM billing practices, particularly for Medicare patients. Since then, CMS and its Medicare Administrative Contractors (MACs) have ramped up audits targeting RPM, CCM, and other virtual care management codes.

A recent article by Carrie Nixon, JD, at Nixon Law outlines the audit landscape in detail, emphasizing that even well-meaning providers can find themselves under review if their documentation or workflows fall out of sync with CMS rules. The stakes are high—financial penalties, recoupment of payments, and even False Claims Act allegations can result from noncompliance.

What Are Auditors Looking For?

According to Nixon, audits are focusing on the following high-risk areas:

• Missing or vague practitioner orders – Services must be tied to a documented, clearly dated, and signed physician’s order.
• Improper documentation of patient consent – RPM and CCM services require documented patient consent; missing this step is a major red flag.
• Lack of medical necessity – Claims must show why services are needed for a particular patient based on clinical conditions and guidelines.
• Insufficient care plan documentation – CMS requires individualized, regularly updated care plans.
• Use of unqualified staff – Only properly credentialed providers can furnish and bill certain services.
• Missing or inaccurate time tracking and transmission data – Codes for RPM and CCM require at least 20 minutes of care team time per month, and RPM device codes require 16 days of data transmission. Incomplete logs or gaps can lead to denials.

Why These Issues Are So Common

Most of these challenges aren’t rooted in negligence. Instead, they arise from the disconnect between complex CMS guidelines and the reality of digital health workflows. Providers often use multiple systems, such as patient intake systems, EHRs, RPM platforms, and care coordination software, that don’t share data efficiently, creating documentation gaps that increase audit risk.

Why the Right Revenue Cycle Management (RCM) Partner Matters More Than Ever

At XiFin, we work closely with RPM and diagnostic providers to ensure billing, documentation, and reimbursement workflows evolve alongside CMS regulations and payor policies. In today’s audit-heavy environment, having an experienced RCM partner is critical—not just for claims processing but also for risk mitigation and operational agility.

XiFin supports providers with:

• Real-Time Compliance Awareness – Clients are provided with proactive updates on payor policy changes and LCD guidance to stay aware of shifting regulations.
• Intelligent Documentation Support – XiFin’s Empower RCM supports the linkage of clinical documentation specific to CPT^®/HCPCS codes, billing requirements, and medical necessity standards.
• MAC-Specific Expertise – We help providers navigate jurisdiction-specific audit triggers and interpret MAC policy nuances to prevent missteps.
• Integrated Claims Data & Workflow Automation – Our platform includes real-time eligibility checks, automated prior authorization routing, and built-in claim validation tools that reduce denial risk before submission.

How XiFin Helps Healthcare Providers Stay Ahead

We partner with healthcare organizations to ensure that their RCM infrastructure supports compliance from the ground up. Here are several ways we help RPM and diagnostics providers stay audit-ready:

1. Timely Payor Policy Intelligence

XiFin’s Payor Intelligence Hub updates clients on the latest trends and insights into payor behavior, LCDs, billing articles, and access to the latest resources.

2. RPM Data Integration Across Systems

XiFin Empower APIs enable two-way, real-time data exchange between internet-connected systems, facilitating “digital conversations” between providers, patients, and payors. This seamless connection is crucial for managing complex processes and systems such as patient intake, ordering, billing, care coordination, and ongoing patient engagement.

3. Advanced Appeals Management

When denials do occur, XiFin’s appeals workflow automation enables:

• Auto-generation of many proprietary appeal letters with payor-specific policy references
• Tracking by payor, CPT/HCPC codes, and reason
• Analytics related to appeal success rates to refine future claims

4. Configurable Dashboards and Forecasting Tools

XiFin Empower Business Intelligence tools provide visibility into:

• Utilization trends by service and code
• Documentation gaps and audit exposure
• Forecasted revenue at risk based on denials

5. Industry Advocacy and Pre-Policy Insight

Through our participation with CMS advisory boards, XiFin helps keep clients ahead of emerging rules. We provide customer updates and assist in interpreting ambiguous billing guidance before it becomes problematic.

Don’t Wait for the Audit Letter

Whether you’re a diagnostics lab, RPM, or digital health provider, compliance can’t be an afterthought. By aligning your RCM with evolving payor requirements, you can protect your revenue while improving operational efficiency.

Let’s talk about how to make your RCM a source of strength in today’s audit-heavy landscape.

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