5 Best Practices When Starting a Chronic Care Management Business
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 more than 550 healthcare organizations nationally
as they’ve established and scaled various Medicare preventive programs.
To be clear: ThoroughCare does not provide consultation to third-party benefit management companies. We are a software company, through and through.
But our experience with patient care programs 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.
If creating such an enterprise is right for you, you may find use in the product we do offer: our intuitive and efficient care management software.
Rules and Regulations for Chronic Care Management
Medicare established Chronic Care Management, 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
- 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.
Providers, on average, receive $42 for 20 minutes of service per month. Additional opportunities to meet higher billing thresholds are available, as we will detail below.
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 150 to 200 patients per month.
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 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 services will be of varying benefit. The quality of service your business provides is only one piece of the puzzle.
5. Be Aware of Billing and Reimbursement Codes
There are five, necessary items required when submitting a claim through CMS:
- CPT Codes for each program you’re managing for the patient
- ICD-10 codes tied to each of the conditions you’re managing within that program
- Date of service
- Place of service
- Provider name
While it’s not needed, it is helpful to know the care manager assigned to a patient in case you’re ever audited:
When billing, you’ll calculate the time spent on CCM for each patient monthly. These are the steps you’ll take when billing:
- Verify CMS requirements were met for each patient each month
- Submit claims to CMS monthly
- Send an invoice to patients receiving CCM services monthly
- Make sure there are no conflicting codes that have been billed
Below is a breakdown of the reimbursement structure your business can use for non-complex care. The following rates are based on national averages, which may vary by the locality:
- For 20 minutes: bill CPT code 99490 for a total of $42.00
- For 40 minutes: bill CPT code 99490 ($42.00) plus CPT code 99439 ($37.80) for a total of $79.80
- For 60 minutes: bill CPT code 99490 ($42.00) plus CPT code 99439 twice ($75.60) for a total of $117.60
- For 20 minutes as a Rural Health Clinic or Federally Qualified Health Center: bill CPT code G0511 tor a total of $67.02
For complex care, use the billing breakdown below:
- For 60 minutes: bill 99487 for a total of $93.00
- For 30 additional minutes: bill 99489 for a total of $46.49
Note: when billing for chronic care, you must have two ICD-10s listed for the patient (as CCM requires two or more conditions).
How Software Can Simplify CCM
As a technology company, ThoroughCare works closely with providers, care managers and other clinical resources. Our business is in software for patient health services.
Care management software is highly recommended for CCM services.
Our software revolves around a patient-centered care plan. Our clinical staff designed the content and workflows to keep patients engaged and healthy.
- A secure, HIPAA-compliant software portal
- Unlimited users and patients
- A live dashboard that tracks CCM service time
- Guided interviews for CCM care plans
- Task tracker (with timer) and time logging
- A monthly update interface for clinical staff and providers
- Care plan reports for the patient and other providers
- A billing interface to easily submit Medicare reimbursement claims
- Tech support via a reliable and secure messaging platform
Regardless of the solution you choose, care management software is a go-to resource for chronic care services.
As you consider your business approach, it will make plenty of sense to include this tool in your plan. Our free guide to care management software is likely a good next step for you. By entering a bit of information, you can download it easily.