Chronic Care Management (CCM) is a point of opportunity, right?
For patients, this Medicare benefit offers continuous care for chronic conditions. For medical providers, the program establishes a new stream of revenue. Others have even found entrepreneurial pursuit in it.
Many have built third-party businesses to capitalize on healthcare organizations that outsource chronic care administration. But, as someone who may have an interest in starting their own CCM consulting business, are you fully aware of the rules and regulations, or the resources required?
Starting such a business may initially appear straightforward. But the ins and outs of this Medicare benefit, as well as the time intensity of providing it, can catch anyone off guard. You could walk into a mess without preparation or knowledge.
At ThoroughCare, we’ve worked with clinics and physician practices across the US as they’ve established and scaled various care management programs, such as CCM. To be clear, though: ThoroughCare does not provide consultation to third-party benefit management companies. We simply provide a software solution to help manage CCM.
But our experience with this program has drilled a broad array of knowledge and perspective into our collective company head. In this article, we’d like to share this expertise to help you determine whether starting a CCM business is right for you.
We’ll cover the rules and regulations of chronic care, as well as best practices when starting a CCM business.
Rules and Regulations for Chronic Care Management
Medicare established CCM so doctors and healthcare groups can provide ongoing treatment to patients between regular appointments. CCM is a monthly program. At least 20 minutes of patient service must be provided each month for Medicare to offer reimbursement.
To enroll a patient, they must have two or more chronic conditions expected to last at least 12 months.
These conditions must pose a significant risk of death, acute decompensation, or decline.
The patient’s doctor must note any chronic issues 12 months prior to CCM enrollment.
Services are delivered through remote interactions.
These can include:
- A monthly clinical review
- Telephone calls
- Physician reviews
- Referrals
- Prescription refills
- Chart reviews
- Scheduling appointments/services
Services are based on a patient’s individual care plan. This document is a comprehensive guide to a patient’s goals, health history, and behavior. It is created in collaboration with the patient when CCM enrollment begins.
Medicare Part B covers 80% of this benefit for patients. Many secondary insurances will account for the difference. Providers and rural health clinics (RHC) can submit claims for this service using the appropriate CPT codes that account for varying degrees of complexity. Reimbursement rates can vary based on locality.
5 Best Practices for Starting a CCM Business
As you strategize or conceptualize your CCM business, it’s best to take certain practices into consideration.
1. Know and Understand General Business Requirements
Whether you’re opening a car wash or launching a start-up, general business elements should be top of mind.
This will ensure your venture is logistically squared away.
For instance, have you determined who your potential customer base is? Will you serve a specific region or provide national coverage? What’s your inevitable tax burden?
More importantly, what client leads do you already have?
Asking these questions will help you prepare. They may also help you understand the potential of your business, as well as further influence your vision of it.
Overall, there’s great benefit in taking the time to prepare. A simple Google search will show you what to do before starting a business.
2. Have Realistic Expectations for Patient Enrollment
Medicare likes to tout how many Americans live with two or more chronic conditions. According to The Centers for Medicare and Medicaid Services (CMS), approximately one in four adults, including 70% of Medicare beneficiaries do.
Medicare introduced CCM in 2015 as a preventative, cost-cutting method to treat these illnesses. And healthcare providers see plenty of potential in this program. It’s possible an even greater share of the U.S. population will endure such conditions in the future. But, does this actually equate to high CCM enrollment rates? In truth, no.
We’ve found that a well-managed program will net about a 30 to 40% participation rate, based on a provider’s promotion efforts and the quality of care. This information may humble your expectations, but it should serve as a reminder. Yes, CCM participation rates have plenty of room to increase, but that’s exactly the point.
There’s plenty of room to scale.
Knowing this reality, versus belief in lofty expectations, will help you make smarter business decisions.
Instead of dreaming of plentiful enrollment, you’ll use the headspace to strategize how best to attract and retain patients on behalf of your clients.
A realistic outlook will ensure your clients, such as healthcare providers, trust your business.
3. Develop a Process and Hire Your Care Team
You should develop a process by which your company will actually provide CCM services. This process should detail the logistics of running the program.
It should include managing enrollment, consent forms, scheduling, and other chronic care activities.
Integral to this process is your care team — the people who will actually interact with patients on behalf of your clients, the medical providers.
You’ll need to hire and prepare your staff, which includes at least one care manager. This designated resource can typically work with 100 to 250 patients per month. This range is based on feedback from providers who offer CCM services.
It would be best to hire based on your expected patient population.
A chronic care manager should either be a practitioner or a certified resource, such as a:
- Registered Nurse
- Licensed Practical Nurse
- Certified Medical Assistant
- Health Coaches (in some areas)
Hiring a certified and knowledgeable staff will introduce various skills and perspectives to your business, ensuring that the process you create is executed well.
4. Think About Effective Patient Engagement
What is the best way to engage patients after they are enrolled in CCM?
When providing service for the patient’s chronic conditions, refer to the care plan for guidance. Managing a patient’s chronic conditions will include:
- Coordination with other clinicians, facilities, community resources, and caregivers
- Ongoing assessment of the patient’s medical, functional, and psychosocial needs through consistent updates of the care plan
- Timely receipt of all recommended preventive care services
- Medication reconciliation with a review of adherence and potential interaction
To keep patients engaged, a patient portal can be extremely effective.
A patient portal allows the patient to view their care plan. It also improves coordination between patient and provider, and it allows for a focused monthly touchpoint of care.
Without effective patient engagement, CCM benefits will vary for patients. The quality of service your business provides is only one piece of the puzzle.
5. Be Aware of Billing and Reimbursement Codes
Five items are required to submit a claim through the Centers for Medicare & Medicaid Services (CMS):
- CPT codes for each program you are managing for the patient
- ICD-10 codes tied to each of the conditions you are managing within that program
- Date of service
- Place of service (most often in-office or telehealth)
- National Provider Identifier (NPI) number
Although not a requirement, it is helpful to know the care manager assigned to the case in the event of an audit.
To bill, calculate the time spent with each patient per month.
Four steps to bill for services:
- Verify CMS requirements were met for each patient each month
- Submit claims to CMS monthly
- Send an invoice to patients receiving monthly CCM services
- Determine there are no conflicting codes that have been billed
When billing for CCM, you must have two ICD-10 codes listed, as the service requires two or more conditions.
Streamline CCM Services With Intuitive Software
Digital software solutions are available to help your practice embrace integrated, coordinated care. At ThoroughCare, we’ve designed our care coordination software for easy clinical use with an intuitive interface that allows you and your team to engage patients through multiple care management and wellness programs, such as CCM.
We offer extensive training opportunities and learning resources. Our tech support team is readily available, and we integrate with several of the leading EHR providers. Our software modules are designed exactly to federal rules and regulations, and they’re easy to use and understand.
Last updated: 2/9/2023
