What is Chronic Care Management?

The Centers for Medicare and Medicaid Services (CMS) announced the CCM program in 2015 as a way to improve outcomes for patients with a chronic condition.  In recognition of the importance of chronic disease management and the impact that it has on healthcare utilization, expenditures, and outcomes, providers can now be reimbursed for care coordination and care management of their Medicare FFS Patients.

How Does Medicare CCM Work?

Quite simply, providers can obtain reimbursement for providing qualified care coordination and care management services for Medicare FFS patients with two or more chronic conditions.


Which Patients Qualify?

Patients must be Medicare Fee-For-Service beneficiaries in order to qualify for CCM services. In addition patients need to have two or more conditions that are expected to last at least 12 months and put the patient at risk for death, exacerbations, or functional decline.



What Services Count Towards CCM?

Any non-face-to-face care management and coordination service provided on behalf of an enrolled beneficiary by a provider or clinical staff member such as:

  • Care plan creation, revision, and review
  • Managing and coordinating patient referrals
  • Managing socioeconomic needs
  • Providing disease self-management education and support
  • Medication reconciliation, overseeing patient self-management of medication
  • Phone calls, emails, and messaging with the patient and caregiver
  • Medication refills




Who Can Provide CCM Services?

CCM services must be overseen by a medical provider. This can include an MD, DO, APRN, NP, CNS, or CNM.

Actual CCM services can be provided by members of the care team under direct supervision of the billing provider. This can include CMA’s, RN’s, LPN’s, and social workers.




What is the Opportunity?

  • 1700 patients per average primary care provider
  • 40% are Medicare patients = 680 patients
  • 70% of Medicare patients are FFS = 476 patients
  • 70% have two or more chronic conditions = 333 patients
  • 75% of patients consent to participate = 250 patients
  • Annual reimbursement at $43 per month per patient = $129,000

Full time team members, such as an MA, performing CCM services on this patient population can generate more than enough to pay for the added expense. Add to this the increased patient satisfaction and retention and improved patient compliance and Medicare CCM is a win-win.



Why Choose Access to Healthcare?

Trained Professionals – Our staff of highly trained healthcare professionals will call on your behalf and coordinate their efforts with your staff, eliminating the need for the practice to hire more staff. At the same time, providers maintain control of the program and have complete patient visibility.

Extensive Care Management Experience – When it comes to taking care of your patients experience matters. Access to Healthcare has more than a decade of experience in providing proven care coordination and care management programs.

A Proven Solution – Our high touch care coordination and care management services have been proven to improve outcomes for patients, reduce unnecessary utilization such as ER visits and unplanned admission, and improve patient compliance.

Seamless Integration – We’ll function cohesively as a member of your clinic’s care team without interrupting the day-to-day workflow of the clinic.

Superior Enrollment and Engagement– Our unique relationship based outreach and engagement methods will ensure you maximize enrollment into you CCM program.

Turnkey Solution – We identify and enroll eligible CCM beneficiaries from your EMR system and deliver superior patient engagement methods. We guarantee complete integration of our services into your workflow and no additional burden to your staff.