Why Should a Healthcare Practice Offer a CCM Program?

Below are the impacts that a CCM program can have for a healthcare practice.

Improved Patient Health:  The main reason for a medical practice to add a CCM program is to improve clinical outcomes for Medicare patients with chronic diseases. Regular calls between the patient and Care Navigator ensures consistency in treating and managing care.

Save Time for Staff: Another critical benefit is to decrease the workload on administrative staff. Our team handles tasks and phone calls for partner practices, which allows them more time to focus on patients in the office.

Increased Revenue Streams: Many tasks are non-billable and take significant amounts of time. Care Navigators handle these tasks while reimbursing revenue for the practice.

How Do We Successfully Implement a CCM Program?

CareTrack’s team works with practices to ensure a partnership that will best benefit the practice and its patients. We address any concerns related to the introduction of the new program for your patients. It follows a step-by-step approach that empowers you to take the reins and seamlessly integrate it into your existing practice workflows.

Embracing an incremental approach, we recognize the importance of starting small and scaling at a pace that aligns with your practice’s unique dynamics.

We create the ideal foundation for success, allowing you to evaluate the program’s impact without obligation, make informed adjustments, and gradually expand to benefit even more patients. We act as an extension of the physician’s team to provide care in between office visits and improve patient adherence to the physician’s prescribed care plans.

How Does the Chronic Care Management Program Work Initially?

Data Analysis: CareTrack performs an in-depth analysis of your patient data to select a small subset of Medicare patients as per the practice’s preference, who would benefit most from chronic care management.

Review: CareTrack and physicians work together to review and understand the care plans of these chosen patients.

Outreach: CareTrack’s dedicated care coordinator connects with the selected patients for Chronic Care Management (CCM) calls and documents the interactions in the Electronic Health Record (EHR).

Billing: Once the care coordinator has completed the CCM calls, you can bill Medicare for these services.

Evaluation: Together, we evaluate the effectiveness of the program and determine the next steps, keeping your practice’s unique requirements at the center of it all.

What Types of Services are Provided Under CCM?

Many patient services are included in a chronic care management service such as:

  • Establishing tangible treatment goals
  • Aligning expected outcomes
  • Medical and systems management
  • Coordination with additional physicians and specialists
  • Caregiver support if needed

How does CareTrack represent your practice?

We work as an extension of your practice. Our team associates ourselves with the practice to maintain patients’ trust. We work with your practice to learn and integrate your practices’ and patients’ preferences.

Can CareTrack be Provided Beyond a Doctor’s Office?

Yes, other common partners include community spaces, care homes, assisted living spaces, and in-home settings. CareTrack remotely communicates with patients in their homes or living spaces between office visits.

Do Telehealth Rules Apply to Chronic Care Management?

Telehealth is governed by complex regulations, both federally and state-wide. CCM utilizes communication via telephone and online, and telehealth regulations do not apply here.

Can CCM Services Be Completely Delegated to Clinical Staff?

Billing physicians are expected to remain involved in the chronic care management of their enlisted patients. They cannot completely delegate this duty to other individuals or entities.

Are the Billing Practitioners Required To See Their CCM Patients Face to Face?

Yes, an initial preventive physical exam (IPPE) is required for new patients who have not had an appointment in the last year. Additionally, practices are expected to encourage new patients to schedule annual wellness visits. These rules require a billing practitioner to meet with the patient prior to enrolling in CCM.

Can More Than One Clinical Team Member Provide CCM Services During a Calendar Year?

No specific CCM regulations are in place regarding this. CCM services can be provided by multiple clinical members if needed, as long as your practice meets all the regulatory requirements.

Example 1: if the provider responsible for CCM is on leave, resigns, or takes over other duties, another team member can take over.

Example 2: if they operate within the scope of practice, team members can contribute to the delivery of CCM services in a specific month.

Does the Patient Have to Provide Written Consent for CCM Services?

Explicit consent from the patient can be in written or verbal form. If verbal, the health record should document the date and time it was confirmed.

Are Electronic Healthcare Technology Systems Necessary to Document CCM Services?

Yes, the billing practitioner/provider should maintain a certified electronic health record (EHR) of CCM patients. Patient treatment plans must be shared with all chronic care team members.

Can CCM Services be Provided by Physicians, Registered Clinical Nurse Specialists, Non-Physician Practitioners, or Other Staff Located Outside the US?

No, all involved parties should be present inside the United States. This also applied to beneficiaries located outside the country.

How Can Non-Physician Practitioners Participate in the Delivery of CCM Services if They Cannot Directly Bill these Services?

Examples of non-physician practitioners (NPPs) who cannot bill directly for CCM services include Certified Medical Assistants (CMAs), Licensed Professional Nurses (LPNs/LVNs), and registered nurses (RNs). Current CMS guidelines identify that NPPs can participate in chronic care management as clinical staff under the supervision of qualified NPPs or health care providers.

How Does CareTrack Help with Annual Wellness Visits?

Yes, this innovative services streamline patients’ annual wellness visits (AWVs). By completing a Health Risk Assessment (HRA) beforehand, our team can better support productive AWVs. The HRA captures patient information that can be completed via phone or online form. Our team sends text message and email HRA reminders, ensuring that patients arrive at their appointment with a complete HRA integrated into your EHR, improving appointment adherence.

How Does Annual Wellness Visit Help My Practice?

This support helps by maximizing time and productivity during appointments, seamlessly personalizing prevention plans, reducing your workload and earning additional revenue for practices annually.

What does the Annual Wellness Visit include?

The AWV includes a Health Risk Assessment that gathers the patient’s medical and family history, current health risks, and vitals. The provider uses this information to provide an individualized care plan to reduce further escalation and risk.

Who can perform an Annual Wellness Visit?

AWVs can be conducted at primary care facilities, specialty practices, and urgent care clinics. AWVs are free of charge to patients, without a copayment. Providers are reimbursed for the service.

Which patients are eligible for Annual Wellness Visits?

Eligible patients have had Medicare Part B for one year and have not had a Welcome to Medicare Visit (IPPE) or AWV during that time frame. After the patient completes the Health Risk Assessment (HRA), the rest of the service is carried out by a healthcare professional. No physical exam is required.

Who do you provide your RPM enrollment services to?

CareTrack can partner with practices and hospitals offering an RPM program.

Which Remote Patient Monitoring devices do you offer services for?

Our team handles patient enrollment for all RPM devices and individualizes our messaging and offering to best adapt to your program.

What is the cost of CareTrack?

Because of the variant changes in reimbursement, pricing changes depending on practice region. Cach patient’s membership cost depends on the patient’s insurance. Contact CareTrack for custom pricing.

Ready for CareTrack to help?

Get in touch with us.