GE Healthcare Camden Group Insights Blog

Chronic Care Management Services: 5 Reasons Physicians Leave Money on the Table

Posted by Matthew Smith on Nov 10, 2015 1:34:39 PM

It has been nearly a year since the Centers for Medicare and Medicaid Services (“CMS”) introduced payment for chronic care management services (“CCM”). As of January 1, 2015, under the Medicare Physician Fee Schedule, physicians who perform CCM can bill for such services using CPT code 99490 and receive a payment of approximately $43 per patient per month. Although CMS estimated that a large majority of Medicare patients would be eligible for such services (as most beneficiaries have two or more chronic conditions), CMS received claims for less than one percent of the estimated eligible population.

So why aren’t physicians billing for CCM when many are performing CCM services? Based on feedback from physicians, professional societies, and vendors, there are five main reasons physicians are not billing for CCM, and this is what your practice should do to correct this.

1. Patient enrollment is difficult and time consuming. Practices are required to have a conversation with patients to inform them of CCM services. Once informed, patients must provide written consent. Most practices are not organized in a manner that they can do this. To address this, practices should develop and implement a marketing and communications plan to introduce this service to eligible patients and educate them on the benefits. Much of the patient education can be done through educational materials, signage, video, and newsletters provided in the office, on the website, or via a patient portal. Education should focus on the benefits of monthly monitoring of the patient’s health. Patients value both high-touch and high-tech approaches. Physician and staff time can be managed if these other tools are used.

2. Copayments create patient dissatisfaction. Patients are responsible for a 20 percent copay for CCM services, which amounts to approximately $8 per month. Since face-to-face encounters are not necessary, it is hard for patients to understand what services they are paying for, and many patients assume this is already a standard part of their care. Thus, the educational process is critical to overcoming this barrier. Patients will pay for services they feel add value to their health. At the same time, it is important to communicate to patients their financial obligations for CCM services. For many, secondary coverage will mitigate their out-of-pocket costs.

3. Electronic Health (“EHRs”) may not effectively support CCM requirements. Although The Health Information Technology for Economic and Clinical Health Act has accelerated the adoption and utilization of electronic health records, and meeting meaningful use requirements fulfills many of the CCM needs, some EHRs may not currently have the functionality to adequately support and/or track CCM services. In the EHR, practices should create a care plan template and a tracker to report monthly CCM activities to ensure requirements are met. Additionally, interoperability challenges exist, including the sharing of patient data among providers. Practices should contact their EHR vendors and inquire about any upgrades or workflow recommendations to support CCM requirements. Also, some EHR vendors offer patient outreach services that supplement the CCM services offered by the practice and, collectively, the services of both meet the billing requirements for the service.

4. Compliance is difficult. To be paid for CCM services, practices must provide 24/7 patient access to care management staff, create a comprehensive care plan for each patient, and document at least 20 minutes of CCM clinical staff time per patient per calendar month, among other requirements. CCM services demand transformation of a practice, including care redesign using a team-based model of care. Practices on this journey or those that implemented medical homes will be better equipped to meet the CCM compliance requirements.

5. CCM services require an investment. Implementing a CCM program creates additional costs, including staffing, technology, marketing, and other general expenses, as well as can increase the physician’s workload. However, the benefits often outweigh the costs. Practices receive new revenue for services they may already be providing, and patients can benefit from more frequent contacts from the practice. By assessing workflows and reassigning certain activities that do not require a physician’s license, practices will gain efficiencies by involving other staff. The practice should perform a cost benefit analysis to understand both the costs and benefits of this service and budget accordingly. Most importantly, the practice needs to consider the strategic advantage of performing such services both in facilitating the move to value-based care and differentiating itself from its competitors.

While cost, implementation, and compliance are challenges, there are many benefits to the practice in pursuing CCM. Practices should not miss the opportunity to use CCM as a driver to position and prepare the practice for future success in a value-based payment environment, while receiving payment in today’s fee-for-service world. Start now! Perform your cost-benefit analysis; identify any gaps in your ability to meet the CCM requirements; implement a plan to address workflows, staffing, and documentation needs. CCM can be a first step in transforming your practice for future success.

Topics: Chronic Care Management, Chronic Care Management Services

Medicare Now Reimburses Physicians for Chronic Care Management

Posted by Matthew Smith on May 28, 2015 2:31:00 PM

Care coordination is a cornerstone of value-based healthcare. It is especially important for patients with chronic diseases, who require complex health services and careful tracking.

Under healthcare reform, physicians have increasingly been expected to provide better care coordination. The problem is that they have received no payment for coordination services not delivered face-to-face. That is now changing thanks to a recent Centers for Medicare and Medicaid ("CMS") decision.

As of January 1, 2015, Medicare pays physicians separately for chronic care management ("CCM") services. This is a potential game-changer for provider organizations transitioning to value-based care. The new policy will help medical practices fund the resources needed to provide care coordination. It can also let organizations leverage quality to strengthen bottom-line income.

Implementing Care Management

In the 2015 Medicare Physician Fee Schedule, CCM services are billable under CPT code 99490. Reimbursement is approximately $43 per patient per month. To be eligible for the payment, services must meet several conditions:

  • Patients: Patients eligible for CCM services must have 2 or more chronic conditions expected to last at least 12 months. These conditions must place the patient at “significant risk of death, acute exacerbation/decompensation, or functional decline.” Patients must provide written consent for CCM services.
  • Parameters: Patient CCM services must take at least 20 minutes of clinical staff time per calendar month. Staff must establish, implement, revise, and monitor a comprehensive care plan. Patients must have 24/7 access to care management staff.
  • Providers: CCM services must be performed by a physician, a non-physician practitioner, or another clinical staff member supervised by a qualified health care professional (under Medicare’s “incident to” rules).

Significant Revenue Opportunity

According to the Centers for Disease Control, two-thirds of Medicare beneficiaries have two or more chronic conditions. As a result, healthcare organizations of every size stand to benefit from the new payment policy.

Consider a solo physician with 500 Medicare patients. Statistically, about 333 of these patients will have multiple chronic diseases. Depending on how many patients qualify for CCM and agree to receive these services, the physician could generate $100,000 or more in additional annual reimbursement.

To realize the full potential reimbursement, providers must meet several requirements. Patients must first agree in writing to receive CCM services. In addition, the practice must meet all documentation requirements, including documentation of staff time.

Care management can create additional costs, including staffing and IT costs and other general expenses. That is why this new payment policy is a great opportunity for organizations that have already built a care management program, such as many acountable care organizations, integrated delivery networks and even some larger medical groups.

For example, consider a health system that already provides care management services for select patient populations. The system has 100 employed physicians who manage patients with chronic conditions. With modest changes to comply with service and documentation requirements, the system could be eligible for several million dollars in new reimbursement for CCM services.

The opportunity for all healthcare organizations is to strengthen the bottom line while providing better care. CCM services can help lower complication and readmission rates, which will ultimately lower the cost of care for patients and payers. 

Careful Planning Needed

To successfully implement CCM, provider organizations need to focus on three priorities:

  • Hiring and organizing clinical staff to orchestrate patient care and manage patient populations.
  • Implementing technology that enables the sharing of patient data among providers, tracking clinical quality measures, and maintaining electronic care plans.
  • Developing effective processes for coordinating care, reconciling medications, managing care transitions, and attaining other CCM goals.

Achieving these goals requires careful planning. But qualifying for CCM reimbursement can help many healthcare organizations transition successfully to value-based care.

Topics: Medicare, Reimbursement, Lucy Zielinski, Chronic Care Management

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