In the face of growing calls for value-based care, reduced reimbursement, and increasing costs, providers are launching care management programs to help counteract these pressures.
While many providers assume their electronic health record (EHR) can support these initiatives, the reality is more complicated.
EHRs were initially built for billing and documentation, rather than for managing complex care coordination and patient-centered care planning. Even with bolt-on modules and plug-in feature sets, clients say their EHR can’t fulfill the role that dedicated care management software can.
When providers attempt to repurpose their EHR for care management operations, they often come to us after experiencing missed billing opportunities, delayed or denied reimbursement, or when facing a program audit.
In this blog, we’ll explore the eight reasons why EHRs are a risky option for CMS care management compliance. Plus, we’ll demonstrate why ThoroughCare not only fills EHR gaps but delivers far more value, efficiency, and compliance.
Figure 1 below highlights how many EHRs handle specific features and Medicare requirements when compared to ThoroughCare. Keep reading to learn how EHR shortfalls necessitate a complementary care management solution.
Figure 1: How does ThoroughCare compare to a typical electronic health record?
At their core, most EHRs are designed to capture clinical encounters, support diagnosis and treatment workflows, and handle billing for in-office, face-to-face care. But CMS care management program workflows require a completely different approach—one centered around non-face-to-face, ongoing patient engagement.
Medicare care management programs require providers to:
Unfortunately, most EHR systems do not offer native workflows for these tasks.
Providers are left trying to manage compliance using manual workarounds, spreadsheets, or disjointed notes, which is both inefficient and risky.
One of the most critical requirements in CMS care management billing is documenting the time spent each month on non-face-to-face services. For example, both Chronic Care Management (CCM) and Principal Care Management (PCM) require a minimum of 20 minutes per month of clinical staff time directed by a provider.
Other Medicare programs require CPT codes tied to time tracking as well, including:
Yet, most EHRs don’t provide any structured or automated way to meet time tracking requirements, including:
These gaps create two challenges.
First, providers risk under-documenting and potentially losing revenue. Second, in the event of a Medicare audit, a lack of verifiable time tracking can lead to recoupments or penalties.
CMS requires that patients consent to enrollment in care management programs.
Consent may be verbal or written, but must be documented clearly in the medical record. Providers must also track whether patients remain enrolled, opt out, or need to re-consent after changes in coverage or care.
Unfortunately, EHRs typically don’t have built-in tools for this purpose, including:
As a result, practices may fail to document consent or re-consent patients on time—both of which could jeopardize compliance and billing.
CMS requires that patients in care management programs have a comprehensive, dynamic care plan that is regularly reviewed and updated. These care plans must include the following elements:
Most EHRs are structured for visit-based documentation rather than longitudinal care planning.
Care plan, if offered, are often templates that providers must create from scratch. They tend to remain as static documents that are buried in the record and rarely updated. This makes it challenging to meet CMS expectations for active care plan management. It’s even more difficult to demonstrate compliance during audits.
CMS care management programs often include required services that aren’t directly tied to individual encounters, including:
These services must be documented, even though they may not generate their own billable codes. EHRs frequently lack fields or workflows to capture these actions in a structured and retrievable way, making it difficult to prove that all CMS billing conditions were met.
Care management programs are not one-and-done activities. Providers must track recurring monthly touchpoints, care plan reviews, and other time-sensitive actions.
Yet most EHRs fall short because they lack features, such as:
This can result in missed monthly contacts (and lost billing opportunities), or worse, accidental overbilling when services were not provided as required.
When CMS audits a care management program, they expect providers to produce detailed, structured reports showing key data, including:
EHRs often can’t generate these reports without custom queries, IT support, or third-party tools.
This creates a serious bottleneck when preparing for audits or efficiently managing a scalable program. Providers who rely solely on EHR data may struggle to demonstrate compliance.
CMS care management purposefully involves team-based care across providers, clinics, hospitals, and even community resources. To meet CMS expectations for coordinated care, providers need to share care plans, document external communications, and track referrals.
Here, again, most EHRs are closed systems with limited ability to interface with outside providers, especially those on different platforms. This undermines the “coordination” aspect of care management, creating documentation gaps and compliance risks.
ThoroughCare supports healthcare organizations with effective, evidence-based care management.
Our team of in-house clinical experts, technologists, and industry specialists helps providers optimize their programs through People, Process, and Technology. Our software was purpose-built to support the unique workflows, communication, and coordination aspects of care management programs, offering:
While EHRs are essential for clinical documentation, they often lack specialized functionality for CMS compliance for care management programs. ThoroughCare fills this gap by providing purpose-built tools that streamline workflows, improve documentation, and support billing.
Rather than relying on patchwork documentation, inadequate EHR functionality, or risky manual workarounds, providers who use ThoroughCare experience new capacity and capabilities.
We help reduce administrative burdens, improve patient care, maximize reimbursements, as well as support better compliance.