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Compliance Advisory
The Compliance Risks of “Block Gapping” in RPM
The hidden risk of “pausing” patient care to avoid failed 99454 months.
Date: December 12, 2025
For: Practice owners, billing leaders, compliance teams
Scope: Medicare RPM device supply (99454)
How to use this page: Operational compliance guide, not legal advice. Confirm payer-specific rules and maintain documentation for medical necessity, consent, device qualification, and billed dates of service.
Quick Snapshot
Risk pattern
“Pause the clock” between cycles
Core concern
Period manipulation + inducement exposure
Better path
Consistent periods
Documented interventions
Explicit episode end/restart
Overview
Medicare RPM device supply billing (CPT 99454) is tied to a hard threshold: CMS describes RPM device supply as requiring a medical device that digitally collects/transmits data on 16 or more days in a 30-day period.[1]
When patients stop taking readings, some teams try to avoid an unbillable month by “pausing” between cycles until adherence returns—often called block gapping. The risk is that pausing can become a billing strategy that distorts the service period, undermines the continuity Medicare expects, and may create beneficiary-inducement exposure if the device remains in the home while billing is on hold.
Section Index
- Key takeaway in one sentence
- What “block gapping” is
- Why auditors view it as high-risk
- The “free device” problem and beneficiary inducement exposure
- Medical necessity and the “on-again/off-again” record
- What to do instead
- FAQ
- References
1) Key Takeaway in One Sentence
If you “pause” 99454 cycles during non-adhesion and restart only when a patient becomes adherent again—while the device remains in the home—you create a pattern that can look like selective billing of profitable windows, increasing denial and audit risk and raising beneficiary-inducement concerns.[1]
2) What “Block Gapping” Is
In a straightforward model, RPM device-supply periods run as consecutive 30-day units once the service episode is established; you either meet the threshold inside each period or you do not. CMS frames eligibility around 16 days in a 30-day period.[1]
Block gapping is the intentional insertion of an unbilled administrative gap between two billed cycles to avoid a likely failed month:
- Cycle 1 bills because the threshold is met.
- The patient stops transmitting.
- Instead of starting the next 30-day period on schedule, the program “stops the clock.”
- The device stays with the patient.
- When readings resume, that day is declared the new start for the next billed 30-day unit.
“Rolling 30 days” is not a license to skip low-adherence time while keeping the episode alive.
3) Why Auditors View It as High-Risk
Selective periods look like manipulation
CMS’ requirement is 16+ days in a 30-day period.[1] Engineering workflows to open only when adherence resumes shapes billing periods to harvest payable segments rather than reflect continuous monitoring.
Cherry-picking is a known RPM fraud pattern
HHS OIG warns that RPM can be abused by billing monthly monitoring that does not occur.[2] Block gapping is different but can appear designed to generate payment without a coherent monitoring episode.
4) The “Free Device” Problem and Beneficiary Inducement Exposure
Block gapping is riskiest when the patient keeps the RPM device during the unbilled gap.
- CMP beneficiary inducement authorities cover remuneration offered to induce beneficiaries to use particular providers/suppliers.[3]
- Remuneration can include free or below-market items or services of value.
- Leaving a device in the home while “the clock is stopped” can create a fact pattern compliance teams must justify.
This is distinct from Anti-Kickback Statute framing; beneficiary inducement exposure lives in CMP authorities.[3]
5) Medical Necessity and the “On-Again/Off-Again” Record
Medicare coverage requires services to be reasonable and necessary.[4] RPM is generally continuous monitoring for ongoing risk. If records show a pause for billing convenience while the device stays deployed, auditors can question why monitoring was clinically necessary only during favorable windows.
Not billing every month is acceptable; shaping the episode to only bill “good months” is not.
6) What to Do Instead
- Keep a consistent service-period definition and track the threshold inside that period.[1]
- When adherence drops, intervene clinically (outreach, troubleshooting, coaching) and document the actions.
- If you suspend or end the episode, do it explicitly: retrieve the device or formally close the episode, and restart with a true new episode and consent as applicable.
- Treat “device stays, billing paused” as a compliance hotspot requiring clear justification.
Time-based management codes may still apply when requirements are met, but they do not justify leaving devices deployed indefinitely without a coherent episode.
How This Relates Back to FairPath
FairPath is designed to prevent silent drift into risky patterns by making states explicit for every patient:
- Active episode: with clear period boundaries and day tracking.
- At risk: pacing alerts surface early warning on threshold risk.
- Suspended/ended: explicit reasons with operational follow-through, including device retrieval policy.
Clarity over manipulation keeps block gapping from becoming an informal “feature.”
FAQ
Patient-requested, clinically documented suspensions are different from systematically pausing low-adherence patients as a billing optimization. The “reasonable and necessary” standard still governs.[4]
Rolling means not tied to calendar months; it does not authorize omitting inconvenient time while keeping the episode active. The requirement is 16+ days in a 30-day period.[1]
Device retrieval with documented episode termination is safer than leaving the device deployed while billing is paused and then restarting when adherence improves.
“Unused” does not erase value; CMP beneficiary inducement authorities consider remuneration to beneficiaries.[3] Leaving devices in the home during unbilled pauses can raise questions in audit.
OIG warns about RPM billing when monitoring does not occur.[2] Gapping can create a similar impression if billing reflects only cherry-picked windows of adherence.
Industry summaries reference shorter-duration device-supply options for 2026, but verify specifics in the final rule and MAC/payer guidance before relying on them.[5]
References
- CMS proposed CY 2021 PFS rule language noting 99453/99454 require “16 or more days of data every 30 days.” federalregister.gov.
- HHS-OIG Consumer Alert: Remote Patient Monitoring (fraud risk warning). Office of Inspector General.
- OIG CMP authorities page mapping §1128A(a)(5) to beneficiary inducement. Office of Inspector General.
- Social Security Act §1862(a)(1)(A) (“reasonable and necessary” standard). Social Security.
- CMS CY 2026 PFS fact sheet (verify shorter-duration device-supply options). Centers for Medicare & Medicaid Services.
- CY 2021 PFS telehealth/RPM fact sheet summarizing 16 days of data in 30 days. team-iha.org.
- OIG Work Plan summary noting RPM fraud/abuse susceptibility. Office of Inspector General.
