The Centers for Medicare and Medicaid Services (CMS) has introduced significant changes in the 2025 Physician Fee Schedule Final Rule, marking this as a crucial year for healthcare organizations. These changes are especially important for those already participating in Medicare care management programs or considering participating in them.
The introduction of new programs such as Advanced Primary Care Management (APCM) and the opportunity for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) to bill for individual fee-for-service care management codes herald a new era in healthcare. These changes offer greater opportunities for providers and health plans to support more patients more efficiently with improved outcomes.
They also demonstrate a paramount shift toward value-based care.
At ThoroughCare, we help healthcare leaders in four key areas:
As you review your organization’s 2024 performance and strategize ahead, consider the following questions:
How do you answer these questions and what tools, support and expertise could facilitate your success?
We believe the path to creating a care management strategy that meets your goals requires four steps, which we outline here. These include:
We suggest the following timeline to develop and implement your care management strategy for 2025. You can use this as a guide to create a more customized timeline, including your quarterly goals.
Because we approach care management through quality improvement, we support holistic transformation across strategy, operations, team and patient engagement, and billing and compliance requirements.
How will your organization decide what fundamental changes to make this year? We suggest three steps to establishing your care management strategy this year. Additionally, there are care quality, operational, and financial aspects to consider when comparing CCM against APCM.
If a Principal Care Management (PCM) or Chronic Care Management (CCM) program is in place, it's helpful to assess the benefits and outcomes of offering them. Answering a few questions can help your organization make strategic decisions.
After gathering facts and observations about programs overall, ask questions specific to the patient populations served. This will be critical to analyzing whether sticking with CCM, adding APCM for some patients or switching to APCM is the best choice.
The essential question to answer through this analysis is which program (or programs) best suits your organization's care, operational, and financial goals. Here, we're primarily focusing on CCM vs. APCM or offering both programs for different patient groups.
The most pronounced difference between CCM and APCM is that the latter does not have any time-based monthly requirements. With APCM, care teams can scale up or down their time investments to match the ebb and flow of individual patient needs from month to month.
This flexibility could allow care teams to enroll more patients. APCM is focused on the availability of advanced primary care services and care management and a patient's risk level.
Sometimes, when a patient is new, receives a new diagnosis or is discharged from the hospital, they require more intense follow-up and coordination. However, with APCM, the practice can invest more time when needed and less when patients are stable and progressing well.
CCM is time-based. This requirement may benefit your organization if it's easy for care teams to meet the 20-minute monthly minimum when engaging patients. If hitting it is challenging and meeting patient needs would be better served without a time requirement, APCM may be a better fit.
APCM bundles programs, including PCM, CCM, and Transitional Care Management (TCM), under one monthly payment. This may streamline your program and free up staff to manage patients with less administrative burden. However, billing each program separately may be more financially beneficial.
While CCM doesn’t have population data or quality measurement requirements like APCM, it does require time tracking. A provider organization’s capabilities and competencies may influence which program fits staff skillsets. Streamlining program management and oversight can enable scaling the program to reach more patients.
While comparing revenue from CCM to APCM is an apples-to-oranges assessment, it's essential to see how one program or a combination of programs (PCM, CCM, and TCM) contrasts with one bundled program in APCM.
Based on the most frequently billed care management codes and the 2025 national rates for CCM and APCM, we’ve created an Excel worksheet that you can update or manipulate to fit your needs. You can estimate revenue based on your actual number of PCM/CCM/TCM enrollees versus if all of those patients were enrolled in APCM.
Complexity: CCM offers a different CPT code and national rate for complex care compared to non-complex care. With APCM, the highest payment for level three complexity is for Qualified Medicare Beneficiaries (QMBs) only. Consider these aspects of the patient population as a factor.
Identify your QMB population: QMB beneficiaries make up approximately 13% of all Medicare beneficiaries. For many providers, this could represent about 10% of older patients. Knowing how many patients have QMB (either partial or full) status, as well as what percentage of your existing care management program enrollees are QMBs, will help determine if APCM is a viable choice.
Assess your population without chronic illnesses: Another unique aspect of APCM is that the lowest risk level and rate covers patients with one or no chronic diseases. If many Medicare beneficiaries could use care management support but not for chronic illness management, there may be an opportunity to enroll them in APCM.
The right care management software platform is one that your team can adopt quickly and easily. It should empower each employee's agency and increase job satisfaction.
Software can support financial goals and become the foundation of an ROI-positive care management service line. It should give your organization confidence in compliance while streamlining reimbursement.
ThoroughCare provides the tools, dashboards, analytics, and reports needed to build any Medicare care management service. We also offer seamless workflows, evidence-based assessments, industry care standards, and best practices on which a team can depend.
Most importantly, we integrate functionality—like AI features—that isn't techie hype. These pragmatic features deliver enhanced efficiency. AI can support more personalized care and help scale programs to reach more patients.
Clinical consulting advisors can bring their extensive experience to help providers further assess their unique situations, patient populations and business objectives. ThoroughCare offers its platform users direct access to our team of clinicians to develop programs and optimize workflows.
This includes:
Strategic healthcare consulting: We can help you answer the care quality, operational and business questions posed earlier. ThoroughCare’s seasoned experts supports your organization in selecting which care management programs best fit your goals, staffing levels and financial picture.
Clinical workflow optimization: Our clinicians collaborate with your care team to streamline workflows and improve outcomes and patient engagement.
Care coordination best practices: We’ll work alongside providers to ensure internal standards are compliant, meet billing requirements, and fulfill each care team's unique needs.
No matter where you are in your value-based care or care management journey, ThoroughCare is here to help you realize your performance, quality and growth goals.
This year is a pivotal opportunity to leverage essential changes and programs.