The high cost of doing business has been met with inadequate increases in reimbursement by CMS and increasing administrative burden due to inappropriate commercial health insurer practices. These issues have created an environment of financial uncertainty.

There is a solution, CMS has expanded coverage for their Medicare CCM Program (Chronic Care Management) including broader eligibility criteria and introduced new billing codes that create new revenue opportunities for providers.

TINs employ and contract primary care physicians and provide services for commercial, traditional, ACO, and Medicare Advantage lives. But there are obstacles that have proven to be difficult to overcome:

• Staffing levels continue to be challenged, depleted, and costly.
• Gaps in Care are identified by EHRs and payor sources, but closing those gaps is challenging.
• The Medicare CCM Program has been created to address issues but TINs struggle to increase enrollment and demonstrate revenue gains.

 So, to succeed, your Medicare CCM Program efforts must be tailored to the unique needs of your TIN, physician group, or individual providers.

Our Medicare CCM Program Optimization platform was designed to enhance the delivery of care across various specialties, including primary care, cardiology, pulmonology, and more.

The platform reduces Total Cost of Care, improves patient outcomes, increases efficiency, unlocks new revenue streams, and transforms your approach to Chronic Care; making it more accessible, proactive, personalized, patient-centered, and effective for the Medicare patients you serve.

It is offered on a Clinic-by-Clinic basis and tailored to your clinic’s specific needs and requires very little workload and no additional staffing requirements.

A Must for Small Independent PCP’s

Being a primary care physician (PCP) in independent practice today means you are running ever faster (and never catching up) on filing more claims to offset the decreasing reimbursement that insurers know they can force on you. But you can increase your revenue and your pmpm within a few months without seeing more patients while maintaining your independence and control of the way you practice.

Our Medicare CCM Program mission is to redefine Chronic Care Management by streamlining collaboration between hospitals, physician groups, and providers. The platform focuses focus on enhancing patient outcomes and simplifying care processes, ensuring those with chronic conditions receive the highest quality of care. By leveraging innovative solutions and fostering strong healthcare partnerships, we are committed to elevating the standards of chronic care, making it more accessible, effective, and patient-centered.

Improved Patient Care

The platform’s strategy revolves around its cutting-edge software and highly skilled staff, including healthcare professionals and support teams, work closely with providers to implement effective CCM strategies, ensuring patients receive the continuous care they need.

Revenue Enhancement

The platform maximizes the financial performance of health systems, physician groups, and providers through a specialized focus on the Medicare CCM Program. Expertise along with unparalleled guidance and support ensures that your TIN will always remain at the forefront of the latest practices and reimbursement.

Advanced Software

Crafted by and for CCM and RAF professionals, the platform is engineered to simplify both patient care and billing practices, ensuring an efficient, seamless experience for healthcare providers and care teams. It integrates effortlessly into existing care routines, offering intuitive tools that streamline patient monitoring, care coordination, communication, billing practices, and more.

Compliance & Quality Improvement

The platform’s comprehensive understanding of regulatory requirements and continuous updates in response to industry changes allows their software programs to support meticulous documentation and care coordination practices, which are crucial for meeting quality metrics, RAF compliance, and improved patient outcomes.

What is the CMS Medicare CCM Program?

CMS’s Medicare CCM Program not only helps manage physical symptoms, but also alleviates the emotional burden of living with a chronic illness. It empowers individuals to take control of their health, offering education, guidance, and resources that foster a better understanding of their condition. Through consistent monitoring and interventions, the program aims to prevent complications and hospitalizations, ultimately enhancing the quality of life.

The platform provides compassionate and professional home health care services. The team of experienced caregivers are dedicated to ensuring the comfort and well-being of your patients, while also providing support and peace of mind to their families. Whether the patient needs in-home care for a loved one recovering from an illness or assistance with daily activities, they are always there to help.

Eligible Patients

Medicare CCM Program 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. *Medicare Part B and many MA plans cover the Medicare CCM Program.

Multiple Chronic Care Conditions include:

• Arthritis
• Alzheimer’s
• Cancer
• Diabetes
• Depression
• Obesity
• Stroke
• Hypertension (High Blood Pressure)
• Heart Disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Asthma
• Chronic Kidney Disease

CMS Medicare CCM Program:

• Chronic Care Management (CCM)
• Complex Case/Care Management (CCCM)
• Principle Care Management (PCM)
• Remote Patient Monitoring (RPM)
• Transitional Care Management (TCM)
• Behavioral Health Integration (BHI)

Industry Changes

• Centers for Disease Control and Prevention (CDC), 6 in 10 adults in the United States have a chronic disease, and 4 in 10 adults have two or more.
• 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 Changes

• Medicare expanded coverage for Medicare CCM Program services including broader eligibility criteria.
• Medicare’s shift towards Value-Based Care (VBC) models emphasizes quality rather than quantity of care provided.
• Medicare has introduced new billing codes to better compensate providers.

Health Systems, Providers & Physician Groups

• Enhance Patient Outcomes.
• Increase Patient Satisfaction.
• Improve Revenue.
• Streamline Workflow.
• Partner with Experts in the Medicare CCM Program.

Patients

• Reduce annual and out-of-pocket medical expenses.
• Dedicated Personal Care Manager.
• Comprehensive Care Plans.
• Health Goal setting.
• Medication management and support.
• 24/7 support.

Patient Onboarding is the Key

The Medicare CCM Program requires that patients:

1. have two or more pre-defined chronic conditions; and
2. have explicitly opted-in to the Medicare CCM Program.

Achieving this opt-in requires dedicated activity. If you have an organized outreach program, supporting technology, and dedicated staff you can expect to opt-in up to 40% of eligible patients.  But TINs who only enroll patients as part of office visits can only expect opt-in volumes closer to 4%.

What You Can Expect

The platform’s dedicated and caring staff, including experienced healthcare professionals and technical support teams, ensure a seamless onboarding process. From providing technical assistance to addressing any concerns or questions, they take care of the rest, so your patients can focus on their well-being and receive the support they need right from the comfort of their own homes.

• Custom Care Plans: Tailored healthcare strategies designed for your patient’s unique needs.
• 24/7 Healthcare Access: Immediate support anytime patients need it day or night.
• Cost Savings: Proactive care to reduce healthcare spending.
• Proactive Health Monitoring: Ongoing checks to keep patient health on track.
• Streamlined Enrollment: Quick and easy sign-up to fast-track the patient health journey.
• Assistance with appointment scheduling and reminders.

Physician Involvement

CMS has configured their Medicare CCM Program to improve physician leverage. But physicians must discuss these programs with a patient during an “initiating visit”, which can be any face-to-face Evaluation and Management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Exam (IPPE).

The physician will also want to collaborate with the mid-level provider who configures each patient’s care plan.  And the mid-level must be working under the direction of a physician – which is not required to be in person or face-to-face.

Once these processes are accomplished, the monthly patient interaction only requires physician involvement at the discretion of a Care Manager.

Mid-Level Providers Carry the Load

One of the primary benefits of the Medicare CCM Program is that patient care and its associated billing do not require regular physician involvement.  Most Care Managers are certified as CNS, NP, or PA.  When using a dedicated software tool, these mid-level practitioners follow Care Plans, document monthly clinical observations, and automatically support billing under the CPT Code set.

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 TIN where the patient relationship resides.

Efficiency is Key for Success

A nursing staff is expensive.  While Medicare Reimbursement does a good job paying for these services, the Medicare CCM Program is a high-volume activity.

On average, Care Manager reimbursement applies in 20-minute segments.  Here are a couple metrics: an 8-hour day consists of 24 of those 20-minute segments.  A week contains 120 segments and a month of 20 working days results in 2,400 segments.  So, in theory, one Care Manager could handle 2,400 patients.  Of course, that assumes 100% efficiency, which is clearly unachievable.  The goal of our top-tier CCM platform protocols is to strive for continuous improvement in efficiency.

Your Complete Medicare CCM Program Partner

The platform team is the leader in CCM because it is revolutionizing the management of chronic health conditions by providing access to compassionate, advanced care and its services empower both providers and patients.

Experienced Nursing Team

The platforms Nurses and Care Teams are comprised of dedicated and compassionate professionals who deliver personalized and comprehensive care coordination and utilize advanced technology for seamless communication and enhanced care delivery.

Billing Optimization

Streamlined automated billing systems ensure that providers can effortlessly capture reimbursement for CCM services, making our comprehensive platform not only a catalyst for better patient health, but also a driver of financial sustainability for your TIN and providers.

Patient Outreach & Education

The patient outreach and education programs are designed to empower individuals with Chronic Conditions by providing them with the knowledge, tools, and support they need to actively participate in their own care.

Dashboard & Analytics

By combining data-driven patient health metrics with revenue performance, reporting empowers your providers to make informed decisions, optimize care delivery, and maximize the financial returns of Chronic Care efforts.

Software Platform

• Designed by experienced Chronic Care nurses.
• Automated record timing to ensure accurate billing code records.
• Built in calling system and patient portal.

Remote Patient Monitoring

• Comprehensive Patient Vitals Dashboard.
• Device integrated patient mobile app that supports devices such as Fitbit, Google Fit, iHealth, Withings, and more.
• Supports reliable protocols like HTTP(S), FTP(S), and TCP/IP

Behavioral Health Integration

• Integrated Behavioral Health screening assessments.
• Built-in logic automatically scores for alcoholism, smoking, depression, and behavioral health.
• CAGE, PACK, PHQ-2, PHQ-9, and GAD-2 screeners and provides recommendations.

Transactional Care Management

• Post-discharge patient services such referrals, medication reconciliation, and evaluation of diagnostic testing.
• TCM checklists to keep track of the crucial timelines and service needs.
• Streamline transitional care to reduce readmissions to hospitals and enhance results.

Patient Eligibility Assessment

The platform performs an eligibility assessment for your existing patient population. Once they identify patients eligible for the program, they will contact the provider for clarification and acknowledgment. Once approved by the provider they will begin reaching out to each patient via preferred communication preferences.

Patient Outreach & Education

The platform’s approach involves a personalized outreach strategy to each patient, where it introduces them to the program and clearly explains to the patient what they can expect. This initial conversation is crucial for establishing trust and rapport. It details the benefits of the program, how it will enhance their care, and the ways in which support can make a difference in the patient’s health journey. Education is at the forefront of this process, ensuring patients are fully informed about how the services will be integrated into their existing care plans.

Patient Enrollment/Onboarding

Patients will receive tailored informative documents that will explain the Medicare CCM Program and why and how they should enroll in the program. Patients will also have the option to enroll over the telephone or through the patient portal. The Patient Enrollment Checklist includes:

• Availability of CCM services.
• Possible cost sharing responsibilities.
• Only 1 practitioner can furnish and bill CCM services during a calendar month.
• Patient’s right to stop CCM services at any time (effective the end of calendar month).

Care Management

The heart of the platform is a patient-centered approach that emphasizes continuous, personalized support. Dedicated care teams consisting of experienced nurses and care coordinators maintain regular contact with patients, ensuring not only the effective management of their conditions, but also fostering a sense of comfort and trust. By integrating advanced technology with a human touch, Chronic Care Connect effectively monitors patient health, adapts to changing needs, and provides educational resources, thus empowering patients to take an active role in their health management.

Reporting, Billing & Analysis

The platform delivers detailed reports on patient progress, health outcomes, and program engagement, allowing providers to monitor the effectiveness of the care plan and adjust strategies as needed. These insights are crucial for optimizing patient care and enhancing health outcomes. Additionally, the platform understands the importance of financial management for healthcare organizations. Therefore, its systems include robust billing reports that offer a clear view of the revenue generated from the Medicare CCM Program services. These reports are designed to streamline the billing process, ensure accuracy, and support compliance with healthcare billing regulations.

The CMS Medicare CCM Program is voluntary, you are not compelled to participate. It’s all about whether you want to increase revenue by billing CPT 99490 and other codes, or not. So, to determine if it makes sense to move forward, we will evaluate data you supply us from your EHR system, Practice Management System, and/or other manual sources.

Our Medicare CCM Program Optimization platform is the empowering solution that ensures you reduce Cost of Care, maximize revenue, remain at the forefront of the latest practices and billing procedures, and succeed with unparalleled technology, guidance, and support.  A reasonable set-up fee applies.

Understanding the financial implications of the Medicare CCM Program helps in making the decision on whether to invest in optimization services or stay the course with your ACO, vendor, or your own efforts very easy.

Take a few moments to download our supporting materials.

• Live Well A.P.S. Medicare CCM Program Optimization Brochure (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)
• AHA 2024 Med Industry Report (pdf).
• HEDIS Measure Subset Impacted Patient Engagement (pdf).

Our Provider Partners are the leading professional service providers and consulting firms that specialize in the processes of the Medicare CCM Program and Patient Outreach Optimization for financial ROI.

They support thousands of independent and hospital-based physicians & clinicians, multi-TIN organizations, ACOs/APMs and their Member TINs. And they are specialists that possess knowledgeable teams of people that handle all necessary tasks, provide frequent reporting, and useful analysis. Their comprehensive understanding of regulatory requirements, continuous updates in response to industry changes and advanced software supports meticulous documentation and care coordination practices, which are crucial for your meeting quality metrics and achieving better patient outcomes.

In a 15-30-minute Zoom call, we will review your CMS CCM database screenshot, which will show you how much more revenue you can capture by billing CPT 99490 and talk about the easy enrollment and set-up process.

Take a moment to download our NCND. Complete and email it to: support@livewellaps.com. Then reserve your Zoom call with us.

1. Click Here to download our Mutual NCND (pdf). We are NOT data miners. Your info will be kept strictly confidential. We will also be sharing proprietary and confidential information with you on the Zoom call.
2. Click Here to go to our Calendly page to reserve your Zoom call (complete the required fields and when asked “purpose of call,” click: Medicare CCM Program Optimization).