A chronic care management solution is the combination of software, staffing, and workflow a practice uses to manage patients with multiple chronic conditions between office visits. It often has a care coordination system, the time tracking for CMS billing codes, and internal staff or an external team that follows up with calls and follow-up. It is important to note the word “solution” because most of the time the program’s success or failure is dictated by the staffing model of the software rather than the software itself.
Often, practices think that the difficult part of starting a CCM program is the software selection. In fact, the challenge is whether to maintain it in-house, outsource the program completely, or use a hybrid approach, in which the practice keeps clinical control of the program and a vendor takes care of patient outreach. The cost structure of each pathway is different, as are their failure points and implications for patient outcomes.
This article takes you through a process of assessing a chronic care management solution based on your practice’s true capacity (and not just the features) and some of the common examples of practices overspending or under delivering.
A Complete Chronic Care Management Solution Includes The Following:
A solution that’s designed for the long haul goes beyond documentation software. It must cover enrollment, continued patient interaction, billing accuracy and clinical escalation if there is a change in a patient’s condition.
The basic elements are typically:
- Diagnosis code and risk factor-based patient identification and eligibility screening.
- Documentation of collection of consent and annual renewal tracking.
- Staffing arrangement: staff members who come into contact with patients each month either internal nursing staff, a contracted care team or a combination of both.
- Time and activity documentation based on CPT codes 99490, 99439, 99487, and 99489 based on complexity and time.
- Escalation pathways to alert a care coordinator to a patient’s worsening symptoms, so they can alert a physician.
- Monthly reporting which compares logged time with billed claims for review of revenue cycle.
If any of these are missing, it tends to limit the program’s growth. For example, a practice with good software but no staffing resources to support it typically brings in more patients than it can treat per month.
In House Staffing Vs Outsourced Care Teams
This is the one decision that most practices underestimate. Operating CCM in-house provides complete clinical oversight, but can involve recruiting or reallocating personnel who otherwise are billable for direct patient care. While that staffing burden is moved to a vendor, there is an added level of communication that must be effective for patients to not notice.
I’ve worked with a mid-sized internal medicine practice that operated both models for six months, an internal nurse with 80 patients and a vendor team with 200 patients. The internal nurse achieved higher patient satisfaction scores but was unable to go beyond approximately 100 patients without an additional nurse. The vendor model grew in size more rapidly but did need weekly calls in for calibration in order to ensure that the escalation criteria were similar to the practice clinical judgment. It was not an objective choice, which one was better, it was a choice between whether in that stage of growth, the practice wanted control or scale.
The Use Of Hybrid Models is Gaining Popularity
Many practices are now doing a hybrid using their own employees to handle enrollment and clinical escalation and outsourcing the day-to-day monthly check-in calls. This helps maintain the doctor-patient relationship while simultaneously relieving the repetitive work associated with contact that is the bulk of the staffing expense. Additionally, it helps to diminish burnout among internal staff as the most time consuming and least complex work is shifted off their plate.
Common Areas Where Programs Lose Revenue
Even with plenty of staff, programs lose revenue in predictable ways. The most prevalent is enrolling patients that technically qualify but for whom there is little likelihood of consistently engaging, thus inflating the number of patients enrolled without providing billable time every month.
The second frequent leak is that the documentation does not use the same language from staff to staff, even though the care may have been correct, this will increase the risk of audit. Using a standard language when documenting on a care team can minimize the risk of audit activity, and the specificity of the note, whether it be “discussed medication adherence” or “adjusted reminder schedule,” will stand out better than “spoke with patient about meds.
The Bottom Line
When it comes to chronic care management, it’s less about the platform offering the most features and more about finding the right staffing, documentation and vendor accountability that your practice can maintain. Successful programs invest as much in the staffing capacity and billing accuracy as in the software itself.
Tellihealth was designed to alleviate the staffing obstacle that slows most CCM programs before they reach maximum capacity. Combines precise and audit-proof time tracking with a care team model that can be flexed from in-house management to outsourced patient interactions to provide practices with chronic care management that scales without straining existing clinical staffing.
FAQs
What’s the difference between a chronic care management platform and a chronic care management solution?
Chronic Care Management Platform describes the software that is employed for documentation and billing, while a CCM Solution is the staffing and processes required to operate the program on a day to day basis. Many vendors will interchange the terms, but practices looking at options should inquire which they are obtaining: Software or Staffing Support.
Is it possible for a small practice to use a chronic care management solution without adding staff?
Yes, usually this is accomplished using either an outsourced or hybrid model in which the vendor’s care team handles the regular monthly interactions with patients, while the practice maintains clinical oversight and the ability to escalate.
How is the revenue of a chronic care management solution usually determined?
Revenue is calculated by CPT codes that are related to monthly time limits beginning with 99490 for the first 20 minutes of qualifying staff time per patient. Time and complexity can help set off the add-on codes, and total revenue is greatly dependent on the consistency of the program logging and documenting time each month.
What are the reasons for most chronic care management claims being rejected?
These include inadequate documentation of time, absence of patient consent or patient’s consent expired, and unclear clinical notes that fail to provide details of the care coordination activity carried out. Having built in documentation prompts and consent tracking, drastically lowers these denial rates.
When can a chronic care management solution be expected to show a positive ROI?
Depending on the practice, ROI can generally be seen within 3 to 6 months when you achieve a critical mass of consistently engaged patients. The timeline is greatly dependent on staffing, as income is linked to contact documented monthly, not to one time enrollment figures.
