Provide holistic care for patients through chronic care management.

Implement a comprehensive, coordinated, and multi-faceted CCM solution for at-risk patients.

How CCM delivers better clinical outcomes

  • Proactive Monitoring: Regular tracking of patient data allows early detection of potential complications.

  • Timely Interventions: Early recognition of issues facilitates prompt adjustments to care plans.

  • Enhanced Communication: Continuous engagement between patients and care teams ensures clear, consistent health updates.

  • Improved Patient Education: Ongoing education empowers patients to manage their conditions more effectively.

  • Tailored Care Plans: Customized strategies address individual patient needs for better treatment outcomes

  • Coordinated Care: Seamless collaboration among healthcare providers results in more integrated and effective care.

  • Effective Medication Management: Oversight of medication adherence minimizes errors and improves treatment efficacy.

  • Data-Driven Decisions: Access to real-time health metrics supports informed clinical decision-making.

  • Reduced Hospitalizations: Early intervention and regular monitoring help prevent emergency situations.

  • Streamlined Workflows: Automated administrative tasks allow providers to focus more on direct patient care, enhancing overall clinical outcomes.

Boost patient participation and engagement.

CCM empowers patients to take a proactive role in their health by providing structured, personalized support and fostering continuous communication between patients and their care teams. We encourage active participation with structured monthly interactions of at least 20 minutes, utilizing built-in communication tools and engagement tracking to simplify the process. Our U.S.-based chronic care managers act as an extension of the office team and integrate regular monitoring, tailored care plans, and education about managing long-term conditions. This collaborative approach not only builds confidence and accountability but also enhances patient satisfaction and outcomes, ultimately leading to greater engagement and participation in their own healthcare journey.

Streamline care management in one place.

Our integrated platform streamlines care management in one place by connecting essential components such as communication, care coordination, medication management, and patient engagement. With built-in tools for automatic time tracking, obtaining consent, and documenting care plans, our system offers a comprehensive solution that ensures better continuity of care through proactive monitoring, timely interventions, and improved health outcomes for patients with chronic conditions. This comprehensive approach empowers clinicians to deliver personalized support while reducing administrative burden. and enhance overall quality of care.

With advanced technology and dedicated managed services, implementing and scaling CCM becomes seamless.

Our U.S.-based care management team integrates seamlessly with your practice, handling patient enrollment, education, and encounters as an extension of your staff. At the same time, our robust platform automates all administrative tasks related to care plan management in full compliance with CMS guidelines, allowing your program to thrive without diverting your focus from patient care.

Seamless CCM revenue cycle.

A seamless CCM revenue cycle is vital for optimizing reimbursements, and it hinges on accurate time tracking and proper coding. Our integrated platform automatically logs each minute of care management activities and applies the appropriate CMS-compliant codes, ensuring that all services are accurately billed. This streamlined process reduces administrative errors, accelerates billing, and improves cash flow, ultimately allowing providers to focus more on delivering quality patient care.

Get started on your CCM journey.

The foundation of our team includes experts in the clinical and business realms of healthcare. Crucial to that are our licensed healthcare professionals who support remote care programs as an extension of your practice.

FAQs

  • There are four CPT® Codes associated with CCM that are reimbursed on a monthly basis:

    99490 | First 20 minutes of clinical staff time per month | ~60

    99439 | Each additional 20 minutes of clinical staff time per month | $46

    99491 | first 30 minutes per month of physician time | ~$82

    99487 | 60 minutes of physician time per month | ~132

    *FQHCs and RHCs can use G0511 to bill for CCM.

  • CCM can be a valuable strategy to support many chronic conditions. The most common include hypertension, diabetes, congestive heart failure, COPD (chronic obstructive pulmonary disease), Alzheimer’s/dementia, arthritis, and cancer.

  • Yes, to qualify for CCM reimbursement, a patient must receive a diagnosis of two or more chronic diseases lasting 12 months or longer.

    • Creating and maintaining comprehensive care plans.

    • Coordinating with other clinicians.

    • Managing medication.

    • Offering assistance for chronic disease self-management.

  • Yes, clinical staff external to a practice can provide monitoring, but it must be under the direct supervision of a qualified healthcare professional (QHCP).

    • RPM focuses on real-time data tracking using devices to monitor patient vitals.

    • CCM emphasizes care coordination and monthly patient engagement for those with two or more chronic conditions.

    • Both services complement each other and can be billed separately for eligible patients.