Most clinics and physicians have hundreds or even thousands of Medicare patients eligible for Chronic Care Management, but in-clinic nurses simply don’t have time to spend 20 minutes a month on each non-visit care calls.

So, there can be no doubts that you have heard about Medicare CCM (MCCM) in the past, or may have participated and fell off. But the time has now come for another look.

There is a federal bill currently moving through Congress, which means you should begin to identify eligible patients who already have secondary insurance and begin prepping the rest of your panel for when the bill passes (see below to learn more).

H.R. 8163 and H.R. 8261

These two bipartisan bills shall modernize the Medicare Physician Fee Schedule to address decades of declining physician reimbursement (the Provider Reimbursement Stability Act of 2026), and eliminate the co-payment that beneficiaries must agree to pay on Medicare CCM (the Chronic Care Management Improvement Act of 2026).

Please support the bills

Listen below to the 6-minute Your Advocation is Needed Now-More-Than-Ever (mp3) and Click Here to download our support flyer (pdf).

 

Until the day arrives when the cost-sharing requirement on chronic care management is eliminated, MCCM Enhanced Relationship Care is still a great opportunity for both physicians and patients when done effectively.

Almost every medium-to-large medical group or practice manager has tried a third-party Chronic Care Management (CCM) or Remote Patient Monitoring (RPM) program vendor in the past.

These fully-outsourced contracts (staffing and all other services) had an initial set of enthusiasm with eligible patients and physicians — but almost always burned them.

The problems:

• Almost all vendors utilize a flawed business model and fail to onboard and retain a sufficient number of eligible patients, and use unethical methods to meet onboarding goals.
• They promise ‘turnkey revenue’—only to leave the clinic exposed to CMS audit risks, EHR documentation messes, or angry patients.
• Their care managers often skip minutes, log low-quality notes, or fail to meet strict CMS Incident-to-Billing Rules, putting the physician and clinic legally on the hook for False Claims Act violations.
• They call older patients, who are vulnerable to phone scams, sounding like a call-center agent, which confuses patients and makes them call the clinic upset, or leave a bad review.
• They promise “turnkey” service, but then bombard the front desk with questions, upset patients with robotic phone calls, or leave the clinic stuck trying to collect $15 co-pays from confused seniors who complain to the doctor.

To make matters worse, most vendors do not do the proper preliminary work required, set any proper level of expectations among physicians and staff, or offer any performance metrics beyond basic billing data:

• No Feasibility Analysis to build effective participation and success.
• No indication of how many patients are currently enrolled.
• No indication of what percentage of eligible patients enrolled.
• No software tools that report on staff efficiency; and
• No easy access to reporting on CPT billing.

These Are Why Top-Performing Clinics Should Only Utilize the Services of Top-Performing Professionals for MCCM.

They have developed the model that de-risks the operational and clinical worries, and delivers maximum value – MCCM Enhanced Relationship Care.

They are:

• The ‘best-in-class’ at identifying MCCM Enhanced Relationship Care feasibility and conducting program management.
• Their skill-set, strategies, tools, and support provide the structure that ensures success.
• Their team is deeply experienced in healthcare and large-scale program implementation and operations.
• Their comprehensive understanding of regulatory requirements and advanced proprietary SaaS technology and continuous updates in response to industry changes, make their platform crucial for meeting quality metrics and achieving better patient outcomes.

Every note is time-stamped and fully compliant under strict CMS Incident-to-Billing Rules—meaning your clinic and physicians get 100% audit and liability-proof protection and full visibility without your staff having to lift a finger or learn new software.

This makes them ideal for becoming your MCCM Enhanced Relationship Care management service partner.

MCCM Enhanced Relationship Care is a major initiative for every clinic and their physicians that goes down the path. In many ways it is a lot like a new business venture. Your best chance of success is to align with a team that provides the best technology and is experienced in big initiatives.

 

Without an initial deep analysis, success is nearly impossible. And with SaaS technology, and a better guidance and support system – clinics and their physicians can double or even triple average enrollment and retention results.

Almost all vendors fail to provide a feasibility analysis, and /or possess the required tech. But this does not mean your clinic, physicians, and patients must take a pass on the improved patient care and enhanced financial performance. The ROI from an MCCM Feasibility Analysis, is well worth the investment.

Our service provider partner offering is built to help your clinic and physicians with evaluating, implementing, and operating MCCM Enhanced Relationship Care successfully. Here are the keys points:

• MCCM Feasibility Analysis – Should you participate in MCCM Enhanced Relationship Care? What are the metrics, physician profiles, and cultures that support success? What physicians and patients should be incorporated? Who shall hire / contract for mid-level billers? At what fee (if any) will the physicians be charged for mid-level services?
• Implementation – They develop and roll out clinical policies, audit-proof reassurance measures, and a low-friction patient micro-pilot. The initial analysis work includes education of administrative and clinical staff, developing patient education materials, setting up clinic responsibilities for patient onboarding, and micro-pilot patient selection. You do not commit your whole patient panel. Once the patients to outreach have been selected, they shall run a micro-pilot on a small number of your eligible Medicare patients who have secondary insurance—where there is zero co-pay. They shall run care management for 60-days, log everything in your EHR,  handle all care calls, and prove the net revenue and patient satisfaction before you commit. With Congress moving to eliminate the 20% Medicare co-pay for its care codes, the biggest patient enrollment barrier is dropping.  They help structure your panel so growth can be captured seamlessly.
• Software Operations – Their proprietary SaaS platform ensures clean documentation, denial control, and program management. It manages the scheduling, clinical documentation, telehealth / calling, and executive dashboarding. And it integrates with your clinic’s EHR and billing system. And there is very little to learn.
• Clinical Staffing – Flexible staffing models support a range of clinic-level strategies. At the full concierge level, they hire, train, and manage all mid-level staff – which you have final approval on to work with your patients. This model can be either a permanent arrangement, or part of your MCCM Enhanced Relationship Care startup-strategy where they phase out their team as you roll in your own employees.

MCCM covers medically necessary care management activities that are performed outside of a face-to-face in-person visit by clinical staff on behalf of Medicare patients with complex health care needs.

• Creates checklists and protocols to manage chronic diseases for eligible Medicare patients via mid-level clinical telehealth visits, which after an initiating visit, are not required to be in person or face-to-face.
• Mid-level nurse/clinical staff (who you help select and assign their billing rights to your clinic and work under your NPI and insurance), work under the direction of your physicians and conduct proactive monthly telehealth outreach.
• Specific care plans for each patient are agreed upon between the care manager (NP) and physician.
• Includes five sets of reimbursement codes which are reported monthly on a timed basis, each set with a base code of 20-minutes and an add-on code for each additional 20 minutes.
• Reduces Total Cost of Care $74.00 pppm by reducing ER and Urgent Care visits and hospital admissions.

MCCM takes care management and makes it proactive and relational, rather than reactive and transactional.

MCCM is Different from Other Telehealth Outreach Activities

MCCM does not change or take away from your current telehealth & patient outreach activities – It adds to them.

The Difference:

• Patients must have 2 or more chronic conditions to be eligible.
• Patients must explicitly ’opt-in.’
• Specific care management templates and engagement policies are required to make it billable.
• Each patient receives at least 20 minutes of telehealth interaction per month.
• Each interaction is billed at MAC location reimbursement level.
• Billing is under the general CPT Code 99490.
• Additional billings are available depending on the level of interaction under the CPT Codes: 99424, 99425, 99426, 99437, 99439, 99487, 99489, and 99491. 

MCCM Landscape

The Opportunity

• Significant Financial Incentive. The per-eligible-patient per-month reimbursement on patients you are already serving that can be captured with MCCM Enhanced Relationship Care can make a huge difference to your clinic and physicians.
• Improved Patient Care. Positive outcome results that enhance patient relationships and create deeper trust, stronger loyalty, a higher star rating, and a reputation for going beyond the visit — with none of the operational burden placed on their staff.

The Challenges

• Compliance. Procedures must be followed to make MCCM billable and to avoid audits.
• Implications On Operations. Additional staffing and workload are required if handled internally.
• Patient Engagement. Specific policies must be followed.
• Initial clinic and physician level education, clinical policy, patient identification, and more are required.
• Staffing. Staffing levels continue to be challenged, depleted, and costly.
• Patient Onboarding. Properly identifying patients and an effective outreach strategy is required.

Eligible Patient Enrollment (EPE)

Not all eligible Medicare patients opt-in, but those that do, value having a clinical team member, nurse, NP, or a PA that they can talk to every month. They also appreciate the:

• Medication management and support.
• Post-visit instruction follow-ups.
• Referral and specialist coordination.
• Urgent symptom triage and guidance.
• Chronic condition check-ins.
• Patient reassurance between visits.
• Reduced annual and out-of-pocket medical expenses.
• Health goal setting.
• 24/7 support.

Participation is Complex

It can be a Large-Scale Project.

• Your clinic and physicians must overcome complex issues across multiple clinics and/or doctors.
• Must align with the goals of your clinic and physicians, which are related – but different.
• Requires the implementation of strategies that are tied to your clinic’s culture and relationship with ownership/board.
• Your clinic or professional service provider must fully “staff up” for implementation.
• The effort must help your clinic gain a unique advantage in overcoming the biggest obstacle to success – patient recruitment and onboarding.
• Must utilize SaaS or AI technology for program management.
• Requires specific patient engagement policies be strictly followed for the program CPT codes to be billable.

Approaching MCCM

Successfully participating in MCCM requires overcoming several challenges and obstacles. The first step starts with answering a few very important questions:

1. Do you know for sure if your clinic and physicians have participated in MCCM since 2015?
2. Have you ever had an MCCM Feasibility Analysis done?
3. Who did or is doing the heavy lifting in your efforts – Your clinic, physicians, and staff or a vendor?

We shall send an email that shall have a link to watch our 6-minute Great Care Doesn’t Have to End video, which is something you should share with your qualified  patient-facing physicians who have long-term relationships.

In addition, a link to your 1-page Medicare Panel Analysis Quickview that shows your revenue potential.

We have made the process very easy and break everything down in quite simple language.

Click Here to request your MCCM Information Email.