The Chronic Care Management Program

Beginning January 1st, 2015 Medicare introduced its Chronic Care Management Program and will reimburse physicians $42 /month, with some regional variances, for providing 20 minutes of non-face to face patient management of chronic illness. (e.g., in Los Angeles its $46.87 /patient/month)

It is noteworthy that CMS is providing this reimbursement as physicians are already conducting chronic care management without reimbursement.

The program allows physicians to create standardized programs that their staff can administer and it provides an “on ramp” to value based care. The requirements however are somewhat challenging and require integration with applications and workflow to create and manage each patient encounter.

We already know that:

  • Manual workflows and processes will not scale to meet the CCM requirements

  • EHRs were not built with the intention of managing populations

  • New technology investments are critical to CCM success

  • With the HIT spotlight fully focused on CCM, numerous organizations are attempting to re-package existing technology as a purpose-built CCM solution.

  • Many vendors in the market are claiming they can support the programs, when in fact they are using existing technology that lacks functionality.

Interest in Chronic Care Management (CCM) continues to grow as industry experts point to the CMS initiative as a fundamental step on the path to value-based reimbursement. Coupled with a sizable incentive for services rendered, CCM extends immediate financial rewards for the value-based workflows of tomorrow.

There is no one size fits all solution.  CMS has explicitly written into the rules the ability for practices to employ “subscription services” to provide the ongoing care management component.

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Costs & Challenges

Delivering CCM services provides a great opportunity for your practice to increase revenue and give you more time with your patients, however there are costs and challenges associated with deploying these solutions that many smaller practices might feel are insurmountable. These include:

  • Hiring new staff to provide service
  • Cost to meet technology requirements
  • Limitations of today’s electronic health record (EHR) systems.
  • Practices must use certified EHRs to bill the CCM code (CPT code 99490) but most EHRs are not designed for non-visit care
  • Most EHR’s are not designed for collaboration among providers caring for the same patient.
  • EHR’s lack the data analysis and automation functions needed to deliver chronic disease care and to create this kind of care plan

How we help – What we do for your practice

How we work and what do we do for practices:

  • Our patient centric technology ensures, every medical visit is recorded, and every provider has access to the documentation via the free application and care team updates. True care coordination. Most EHR’s are unable to fulfill all requirements – specifically electronic access to Care plan by patients and all their providers, our solutions fulfills all aspects needed.
  • Our Health Assistants collect medical records from all a patient’s providers to build a comprehensive Care Plan and health summary that includes the CMS-required elements
  • Our Health Assistants spend a minimum of 20 minutes per patient, per month assisting with care coordination tasks including scheduling medical visits, reconciling medication lists, updating care plans, adherence and more
  • Our Health Assistants are available 24/7 by phone, online, and through in-app messaging to help patients with acute chronic care issues and care coordination tasks
  • Our Health Assistants facilitate care transitions, document the information, and keep all members of the care team up-to-date.
  • We offer the revolutionary ability for families to access & interact with information, share it before visits, listen to a recording of the doctor’s instructions, and respond to notifications when a reminder is missed.