By Lucy Zielinski, Vice President, GE Healthcare Camden Group
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.
Ms. Zielinski is a vice president with GE Healthcare Camden Group, with over 20 years of experience in the healthcare industry. She specializes in helping private and hospital-owned medical practices achieve top financial performance by guiding physicians through practice development, strategic planning, coding and revenue cycle process optimization, and electronic health record system implementation. In her health system leadership roles, she has successfully managed the revenue cycle for over 2,000 physicians. Additionally, Lucy has led engagements with physician billing companies that involved restructuring operations and development of dashboard reports. She may be reached at firstname.lastname@example.org or 312-775-1700.