ACO SUPPORT
CMS SPECIFIC MEDICARE CCM PROGRAM (M-CCM) FOR ACO
Overview
When it comes to Medicare, reimbursement has always been the problem. Everyone knows it. To address this, CMS created the specific Medicare Chronic Care Management Program (M-CCM).
Most ACO member clinics and their providers are NOT participating. There are several reasons for this; M-CCM is telehealth interactions by mid-level nurse practitioner’s – physician-based CCM & telehealth outreach is staff centric. There is confusion between the two, which has resulted in under-utilization. CMS wants this to change NOW.
M-CCM does not change or take away from your member clinics current CCM and/or telehealth outreach activities – It adds to them!
CMS configured the program to help ACO’s reduce Total Cost of Care and increase shared savings distributions, and help member clinics and their providers capture additional reimbursement, maximize financial performance, simplify care processes, and more.
The program takes care management and makes it proactive and relational, rather than reactive and transactional. And the program is the missing piece of your member clinics reimbursement puzzle.
A Must for PCP’s
Primary care physician’s (PCP’s) are running ever faster (and never catching up) on filing more claims to offset the decreasing reimbursement that insurers know they can force on them. But the M-CCM Program can help them capture the additional CMS reimbursement they need within a few months, while maintaining control of the way they practice.
Why M-CCM is Mission Critical for ACOs
- CMS estimates that M-CCM reduces Total Cost of Care by $74 pppm.
- M-CCM and ACO overlap in mission-critical areas.
- Chronic condition-based quality.
Where clinical Quality Measures reference chronic conditions, the presence of M-CCM goes far in sustaining visibility into chronic patients. And visibility is a first step in managing quality.
Chronic Condition-Based Cost
Cost measures are completely based on Medicare patients. This makes M-CCM particularly powerful in the ability to influence utilization of expensive services, by pre-empting the need with ongoing clinical care.
Physician/Clinic Relationship Management
Imagine a scenario where your activities generate new revenue for your member physician population - daily. In some cases, you enable those revenues in ways the physicians cannot. Might that improve clinic/physician recruitment and retention?
Patient Recruitment (REACH-Model ACO)
REACH-Model ACOs are allowed to provide incentives to patients to be a member of the ACO. What better incentive for a patient than having monthly access to their own nursing staff?
Physician Involvement
CMS has configured the specific program to improve physician leverage. A physician, a nurse on their staff, a care manager or nurse or NP on your ACO staff, or an outsourced certified mid-level NP - on the physicians behalf (who assign their billing rights to the physicians organization and work under their NPI and insurance) are the only authorized people that can discuss the program with a patient (this can be done in-person or on the phone). Then the patient must schedule an ‘initiating visit’, which can be any face-to-face evaluation, management visit, annual wellness visit, or initial preventive physical exam. This creates indirect benefits in terms of generating more engagement and thus more in-office visits and more billable events for the member clinic and provider.
Physicians collaborate with the mid-level nurse who configures each patient's care plan. And the mid-level work under the direction of a physician, which is not required to be in person or face-to-face. Patients receive 20-to-30-minutes of telehealth interaction per month. Each is billed on a time basis at the local MAC reimbursement level. Primary billing is under CPT Code 99490 with additional billing codes based on the level of interaction.
Once the processes are accomplished, the monthly patient interaction only requires the physician’s involvement at the discretion of a care manager.
Mid-Level Providers Carry the Load
One of the primary benefits of the M-CCM Program is that the telehealth outreach, patient care, and its associated billing do not require regular physician involvement. Care managers do not need to be employees of the billing clinic. They can be employed by an ACO (or other third party) and simply re-assign their Medicare billing rights to the organization and their providers where the patient relationship resides.
Eligible Patients
M-CCM services are a Medicare-covered benefit for individuals with multiple chronic conditions that are expected to last at least 12-months and put the patient at significant health risk. The program not only helps manage physical symptoms, but also alleviates the emotional burden of living with a chronic illness.
The program empowers Medicare beneficiaries to take control of their health by offering education, guidance, and resources that foster a better understanding of their condition. Through consistent monitoring and interventions, the program aims to prevent complications, hospitalizations, and ER and Urgent Care visits. And ultimately enhance the quality of life.
Why the Program Matters
- Over two-thirds of Medicare beneficiaries have two or more chronic conditions.
- A Patient-Centered Primary Care Collaborative found that comprehensive CCM can lead to a 20% reduction in hospital admissions for patients with chronic conditions.
- CMS wants all qualified providers to get on the uptake NOW.
Benefits to ACOs
- Meets ACO mission goals.
- Reduces Total Cost of Care.
- Improves clinic/physician recruitment and retention.
- Increases shared savings distributions.
Benefits to Member Clinics & Providers
- Improves patient outcomes.
- Increases patient satisfaction.
- Captures additional CMS reimbursement.
- Maximizes financial performance.
- Streamlines workflow.
Benefits to Eligible Patients
- At least 20-minutes of telehealth interaction per month.
- Reduces annual and out-of-pocket medical expenses.
- Dedicated personal care manager.
- Comprehensive care plans.
- Health goal setting.
- Medication management and support.
- 24/7 support.
Feasibility Analysis is Required for Success
Without a deep analysis, program success is nearly impossible. This is why both vendors and ACOs have failed to generate adequate program adoption and enrollments. The program is a complex initiative. It is very much like a new business venture. Therefore, it is prudent and desirable to first test assumptions, define strategies, evaluate data, and develop plans that would enable results that meet the goals and needs of your member clinics and their providers.
The analysis completes all preliminary work necessary for program success (i.e. establishing clinical policy, providing physician education, conducting patient identification, developing the patient engagement/ onboarding strategy, and more). This combined with a full-service support system, SaaS technology, and a team experienced in big initiatives – your member clinics and providers can double or even triple average cadence results.
Our Offering
Our offering is built to help your ACO, member clinics and providers with evaluating, implementing, and operating this specific Medicare program. Here are our key success offerings:
- M-CCM Feasibility Analysis – Should member clinics have the program? What are the metrics, physician profiles, and cultures that will support success? What physicians and patients should be incorporated? Who will hire / contract for mid-level billers? At what fee (if any) will the physicians be charged for mid-level services?
- M-CCM Implementation – We develop and roll out policies supporting the program. Implementation services also include education of administrative and clinical staff, developing patient education materials, setting up organizational responsibilities for patient onboarding, etc.).
- Software Operations – Unique software manages the scheduling, clinical documentation, telehealth / calling, and executive dashboarding. It integrates with your clinic or organization’s EHR and billing system.
- Clinical Staffing – Our flexible staffing model supports a range of clinic-level strategies. At the full concierge level, we hire, train, and manage all mid-level staff (usually Nurse Practitioners). This model can be either a permanent arrangement, or part of member clinics startup-strategy where we phase out our team as you roll in your own employees.
Why Our Service Provider Partner is the Best Choice
Many healthcare executives are curious about the program because they are doing CCM and telehealth outreach activities. Many claim their ACO handles the program, which have been unsuccessful, or have contracted with a CCM vendor on a fully-outsourced contract (staffing and all other services), which had an initial set of enthusiasm with eligible patients and physicians but has fallen off.
Fall off is most often due to not having done the proper preliminary work, set a proper level of expectations among physician staff, and not having any performance metrics beyond basic billing data. These include:
- No feasibility analysis
- No indication of how many patients are currently enrolled;
- No indication of what percentage of eligible patients are enrolled;
- No software tools that report on staff efficiency; and
- No easy access to reporting on CPT 99490 and 99487 billing.
Utilizing EHR for M-CCM Program Management
For ACO and/or member clinics currently offering eligible patients M-CCM and utilize their EHR for program management, may require technology that integrates and provides all necessary billing data. Our SaaS Technology Platform could be the perfect solution because its advanced software tools scale M-CCM efforts upwards.
Request Your ACO M-CCM Info Email
We will send an information email with several links. The first 2 will provide a quick overview of the program (synopsis video) and 3 of your member clinic’s additional annual reimbursement potential (CMS M-CCM Data Set Snapshot). In just a few minutes, your decision makers will know if they want to take the next step. Links 3 & 4 will provide the detailed information they need. We make the process very easy by breaking everything down in quite simple language.
Forward the email to all decision makers at your ACO that will need to view the information. And if required, have a meeting to discuss scheduling a 30-to-60-minute Zoom call meeting with our team. Click the Zoom link at the bottom of this webpage.
Click Here to request your ACO M-CCM Information Email.
Supporting Materials
Take a few moments to download our brochure, FAQ, and CMS data supporting materials below
- Live Well A.P.S. ACO Medicare CCM Brochure (pdf).
- Live Well A.P.S. ACO Feasibility Analsis FAQ (pdf).
- CMS MLN CCM Booklet (pdf).
- Medicare Chronic Care Management for Seniors article (link).
- CMS Outreach and Education on CCM report (pdf).
- Mathematica 2017 report on CCM (pdf). (This is an important study, but a bit long. See page 64 for the Bottom Line)
MACRA FOR ACO
MACRA requirements make up thousands of pages of regulations in the Federal Registry and are a very complicated beast and no small task to manage or optimize.
Though most ACOs did a good job meeting Quality Measures in the past, many are missing the opportunity to help Member TINs qualify for the maximum payment adjustment of up to 9%.
MACRA is Worth Money$$
The high cost of doing business has been met with inadequate increases in reimbursement by CMS. But MACRA can actually help.
Make sure your Member TINs don’t leave any money on the table. Help them qualify for up to the maximum payment adjustment in the next PAY.
Understanding the financial implications of the QPP & MACRA helps in making the decision on whether to invest in MACRA Optimization / Registry Services or stay the course with your ACOs current effort - very easy.
The only thing worse than failing to maximize your member TINs payment adjustment is not taking the simple steps to help them qualify for it. And that’s exactly what many ACO decision makers are doing.
MACRA Facts
The QPP & MACRA went into full effect on January 1st, 2022. But up until 2024, it was just a compliance checkbox issue and a nuisance. But now eligible ACO Member TINs, physicians, and clinicians receive a positive or negative payment adjustment of up to 9% more, or up to 9% less on their Medicare Part B claims submissions, based on your ACOs (or their own) Corresponding Performance Year Final MIPS Score (note* Critical Access Facilities & Federally Qualified Healthcare Clinics are exempt).
MACRA requirements make up thousands of pages of regulations in the Federal Registry and are a very complicated beast and no small task to manage or optimize.
Though most ACOs did a good job meeting Quality Measures in the past, many are missing the opportunity to help Member TINs qualify for the maximum payment adjustment of up to 9%.
The MACRA Optimization Cycle
Optimization consists of a 9-step process that can only be achieved with an Active or On-Going Program that follows a regiment of extract, report, analyze, plan, and act for each quarter or month. And only by taking each step can your ACO earn an exceptional Category Weights and a Final MIPS Score that will qualify your member TINs for the maximum payment adjustment in the next PAY.
Technology That Provides More Than EHR
Who Needs It? (Epic, Cerner, Allscripts, eClinical Works) - Almost All EHR Users
EHR’s can't submit MACRA data directly to CMS. In fact, it can be hard to even analyze MACRA data in meaningful ways. That's why the platform subscribers get better reimbursements, with less manpower.
Physicians Buy EHR for Patient Care - Not for Fast-Moving Regulatory Compliance
Managing MACRA from a physician point of view should be a by-product. We find that even the best EHRs only keep up with MACRA at the superficial level of creating numerator / denominator values, and honestly - those rules don't change much.
CMS Publishes Hundreds of Pages of New MACRA Rules Each Year
Our platform relies on EHR to do the numerator and denominator work but does all the rest relating to those hundreds of pages.
EHR Plugin
Our platform is a cloud-based tool that connects to EHR with no local software needed. And our enhanced reporting and sophisticated concierge team will take it to the next level - beyond simple numerator / denominator content.
Whether EHR is sophisticated enough to create QRDA3 output, a simple spreadsheet, or just a PDF - connecting to the platform simplifies connecting to CMS.
Automated Data submission
With our platform there is no need to manually submit or upload data via EIDM. It provides an automated streaming API directly to CMS, with automated response and tracking at the level of TIN, Provider, MIPS Category and Measure.
MACRA Financial Projections
Our platform automatically queries CMS for Medicare billing and payment history for each provider. Then it applies statutory minimum / maximum expectations based on each year's MACRA rules, adjusted for estimated CMS Scaling Factors. It then sets budgets that tie operational performance with financial performance. Finally, as it accumulates PI, CQM, Cost, and CPIA data throughout the year, it displays actual financial results against these budgets.
Provider Dashboards and Scorecards
Our platform's excellent dashboard integrates financial performance with MACRA operational performance in uniquely powerful models. It flags individuals, TINs, and customizable groupings against operational targets throughout the year. And it provides potent provider communication tools that clearly share the impact of performance.
Analysis of Alternatives
As our platform tracks actual performance data throughout the year, you will have instant visibility into which submission models (Group / Individual, EHR / Registry, ACO / Advanced APM / Standalone), which earns the greatest MACRA reimbursement.
Physician Compare / Review and Correction Cycle Management
Submission is not the end of your MACA Season. CMS ultimately will echo back their understanding of submissions, and gives the chance to agree, or to submit data for further review. Our platform gives provider groups the tools to manage the overall process.
Complex TIN and Provider Organization Management
No one tracks complex organizations like our platform. Its tools incorporate not only TIN dashboarding but also identify the key workflow steps that keep track of progress across complex TIN structures.
Software + Concierge
Because our platform is independent of EHR and Registry offerings, it is in a unique position to identify, configure, and submit your very best MACRA options. It often blends from multiple offerings, which really fine-tunes your result.
Tools and Consulting Combined
Not even the best tools stand alone. And not even the best consultants can organize and optimize complex data. We believe your needs include both consulting and software thoroughly integrated.
Your Concierge is always available for help with any MACRA tasks. Our platform’s software integrates with any EHR and any Registry to give you the best of both worlds.
MACRA is much more than a year-end submission exercise or a periodic measure calculation.
You can’t improve performance by looking at your metrics after the year is over. And simply making numbers available a couple times a year only improves things a little.
At times, your ACOs Category Weights and Final MIPS Score may not be complete and/or accurate. And while some solutions can be applied retroactively, many require that coders or physicians change the way they describe things or even change physician behavior.
Many so-called MIPS or MACRA experts’ (vendors) give lip service to CMS quarterly or monthly requirement of integration and feedback. They get by with a dashboard that clients can look at any time. Such a passive approach is NOT dependable. The fact is – a dashboard is the least dependable of all.
What Else is Required
For your Member TINs with fewer than 100 physicians & clinicians, it should be enough to run reports from your EHR quarterly, post them to a standalone MACRA database for performance analysis, and discuss shortfalls against targets. For complex multi-TIN organizations, MACRA Optimization steps need to be done monthly.
Sophisticated program analytics is required because raw MACRA data doesn’t mean a lot to ACO and TIN management, physicians, or clinicians. By adding the financial impact, this creates a clear frame of reference. And once CMS publishes their Physician Compare content, the MACRA team should study the impact of public scores on the flow of new patients.
Many of your mid-to-large sized Member TINs may need at least one person with the expertise, time, and resources (including access to external expertise) to maintain or achieve the highest performance status.
If your ACO is already working with a MACRA or MIPS vendor or Registry, you still need an independent 3rd party review of their work to ensure they’re following up on all requirements. Because you can’t afford to find out if they’re not after the fact.
We will also help your ACO identify areas that need improvement for getting a patient scheduled for Medicare Chronic Care Management (M-CCM) conditions.
Payment Adjustment Remittance Verification
In PAY 2025, CMS reports that more than 21% of all MIPS eligible TINs, physicians, and clinicians will be penalized with a negative payment adjustment.
It is estimated that more than $4 billion will be redistributed to 2023 top MIPS performers in 2025.
Your Member TINs can find their payment adjustment in their QPP Detailed Final Report. But they need to verify the payment adjustment on each claim they submit because it will not be easy to identify and will require a bit of calculation to show if it is correct. It will show as a dollar amount on their remittance advices, but to determine if it is accurate they will need to convert it to a percentage and compare it to the expected percent for the submitting physician, which will not appear on their remittance advices. Our Payment Adjustment Remittance Verification pulls the expected percent from the CMS / QPP database and compares that value to the value calculated on your Member TINs Remittance Advices.
Your management team needs to contemplate the value of the payment adjustment in the Medicare Fee Schedule under the QPP & MACRA to those same TINs knowing that a single point (increase or decrease) in MIPS score will probably be worth up to $250k or more.
Some of our MACRA solutions will be oriented towards your ACO (i.e., calculation of eCQMs under optional / mandatory regulations, and real-time calculations of ACO-level MACRA (MIPS) scores throughout the Corresponding Performance year (CPY), and others towards your Member TINs (i.e., enabling a hierarchy of CQM, PI, IA, & Cost evaluation and submission and Patient Engagement options that can enhance the TINs Payment Adjustment Year (PAY) revenue and reimbursement beyond ACO-level results).
We will help your Member TINs earn that return and probably for considerably less than half the cost of a single new hire.
eCQM
As CMS incentivizes ACOs to integrate eCQM into their reporting repertoire, your Member TINs will look to your ACO for guidance. We provide the needed knowledge, tools, and people to support all required data collection, communication, and analytics to help. And quite probably do it for less than the cost of one employee.
Our formal process for optimizing MIPS (Category Weights Scores) proves that early corrections have big impact, and that year-end (submission-time) analysis has little or no impact on improvement.
Advanced APMs
Advanced APMs are exempt from MIPS. However, most if not all physicians will likely fall into “Partial QP” status due to the QP threshold increase from 50% to 70%.
The impact is that Partial QPs are optional MIPS submitters. But with your normal high performance, submissions should earn your member physicians more than their historical QP reimbursement of 5%. (Note: by electing to not submit they receive zero).
Here is the best option going forward - First, as Partial QP’s, submission should be made by all TINs individually, and the ACO-level CQM submission does not apply. In this approach, we fulfill the role of ACO support by interacting with each TIN throughout the year to optimize their own Category Weights Scores. For all but one TIN, this will involve generating CQM data from their Certified EHR. This approach will avoid any chance of penalties and maximize earning & efficiency for your Member TINs.
ACO MACRA Snapshot
We will show you what your ACO and member TINs MACRA opportunity looks like. We will email you a pdf of a CMS data snapshot on your ACO and a few of your member clinics, which will show you how much more revenue can be captured with MACRA optimization.
The summary will break down the data for you in very simple language.
ACO MIPS Data Analysis
This analysis is an invaluable tool to present to your board and member TINs. It will include an MACRA Strategy Report and data spreadsheet that calculates your MIPS opportunity based on the current PY.
Reserve a Call with Us
In a 30-60-minute Zoom call, we will talk about your snapshot, our qualifications, and our Strategy Report that will show you how much more reimbursement can be captured, and how we can help your ACO meet its mission goals and provide you with something you will be proud to show your board and member clinics.
Click Here or see the link below to go to our Calendly page to reserve your Zoom call with us. Complete the required fields and when asked “purpose of call,” click: ACO Support – MACRA.
Supporting Materials
Take a few moments to download our brochure and supporting materials below.
- Live Well A.P.S. MACRA Brochure (pdf).
- 2025 CMS Final Rule (pdf).
- Qualified Registry - A Pathway to Success within MACRA (pdf).
- NQS Report (pdf).