Specialty providers are often hesitant to start a Chronic Care Management program for a variety of reasons. Will I upset my referring providers who may have a program of their own? Does that mean I have to take over managing all of my patients’ chronic conditions? How does CCM fit into my treatment plans for my patients?  

Let’s answer some of the questions above as we explore the benefits a CCM program brings to a specialty practice. 

Referring Providers 

The CMS Chronic Care Management initiative was first introduced in 2015 and has seen incremental reimbursement increases and adoption from additional carriers in the years since. Intended to decrease gaps in care, unnecessary hospital visits, and to reimburse providers for care outside of office visits, CCM is beneficial to both patients and the bottom line of a medical practice. While momentum for CCM and other remote care services is building due to Covid as well as higher instances of chronic conditions in general, surprisingly few practices have chosen to implement a program. 

While every practice may have a different perspective on CCM, here are several reasons your referring providers may not have instituted a CCM program: 

• Many primary care practices choose to seek alternative reimbursement models or capitation, which may exclude them from billing CCM services separately.   
• There was a nationwide nursing shortage even prior to the Covid pandemic.  Pulling a qualified clinical staff member out of regular patient workflow to focus on CCM may not be an option.   
• Many specialties, including primary care run on very tight margins.  Justifying the startup costs of an in house CCM program could be difficult, especially given the increased expenses caused by inflation.   
• Maximizing a CCM program may require specialized software or analytics tools.  Implementing software can be expensive and time consuming.   

• Some practices tried CCM early on and didn’t either have the tools, the capital or the right partner/vendor to keep it going, so they discontinued it or let it wind down on its own.  

If you do choose to start a CCM program and have referring providers who do have a program of their own, you can always opt not to contact patients that belong to those practices while starting your program.   

Managing Other Chronic Conditions 

Scope creep can be a big problem for specialists. There are always patients who come to your practice that don’t see their primary care or other specialists regularly and you end up assisting that patient far more than you’d prefer with coordinating care for their other issues. Regardless of whether you treat a patient’s other chronic conditions or not, a specialist has a responsibility for documenting those conditions for the purposes of assessing how they interact with the conditions the specialist is treating. Medication reconciliation is another challenge that all providers face as they must know what medications a patient is taking prior to prescribing medications of their own due to potential interactions. 

A CCM program can provide support for each of the above situations. Documentation of a patient’s other chronic conditions improves because chronic care nurses aim to discuss and document all the patient’s chronic conditions. The care given by other providers, all medications that are being prescribed along with how well they are being taken and tolerated, as well as the current status of each condition and it’s recommended treatment program is documented. Care managers also assist the patient with socioeconomic issues such as the patient’s ability to afford medications, need for meal assistance or transportation to appointments.   

While the provider managing the CCM program will be alerted to urgent issues with chronic conditions they aren’t treating, patients should be referred to the appropriate resource to resolve the concern – whether that be to their primary care provider, other specialist, or ER in the case of emergency. As every provider’s referral patterns and preferences are different, the CCM team should be given pre-determined guidelines on where patients should be referred for specific conditions if a resource is not already in place for that patient.   

Specialty-Specific Benefits 

Chronic Care Management and other remote care programs are applicable for many specialties. Here are a few examples of specialty-specific benefits of implementing a CCM program: 

Pain management – There are well-established guidelines for documentation for the treatment of chronic pain – including the requirements for the new 2023 Chronic Pain Management G codes which allow providers to get reimbursed separately for pain management for the first time ever. Providers typically document things such as causation, pain scores, activities of daily living, side effects, amelioration, aggravation, and treatment goals. CCM requires the implementation of care plans, which can be configured to gather much of the required documentation – saving staff time in the office.  Standardized screening tools such as ORT, GAD7, PHQ9, Oswestry Disability Questionnaire, Activities of Daily Living, and VARS assessments can deployed by the CCM team. CCM staff can also handle post procedure follow up to document procedure outcomes and recommend scheduling follow up procedures. 

Orthopedics – Documentation for procedure follow up is critical in coverage of future procedures as well as patient discharge from care. The CCM team can assist with post-procedure documentation, alert the practice to procedure adverse reactions, and to assist with scheduling follow up appointments. There are additional remote care options such as Remote Therapeutic Monitoring (RTM) which are codes related to CCM that can be billed in addition throughout the treatment plan period. 

Cardiology – Cardiologists often manage multiple chronic conditions for a patient, making them ideally suited for CCM.  Medication compliance and quickly identifying medication reactions is critical in cardiology patients.  CCM nurses speak to patients at least monthly, giving cardiologists more regular and consistent documentation and education for a wide range of topics including medication management. Many cardiology patients require socioeconomic assistance or Transitional Care Management after hospital discharge which can also be provided by the CCM team.  

Overall CCM Benefits 

• Reduced attrition and additional appointments for office visits and procedure repeats 
• Increased patient satisfaction due to additional touchpoints to answer questions 
• Better charting and documentation 
• Prevention of unnecessary hospitalizations and condition escalations 
• Fewer phone calls to the practice by utilizing internal messaging to relay refill and appt requests 
• CMS/MIPS Quality measures increase 
• Enhanced patient compliance with medication and treatment regimen 
• Consistent patient education 
• New resources for patient socio-economic needs 
• Monthly revenue from CCM services 

How Outsourcing Can Help 

At Harris, our CCM team acts as an extension of your practice. Our specially trained care managers are here to assist your CCM patients with a myriad of factors including questions about medications and treatment recommendations, appointment and refill requests, socioeconomic assistance and more. As detailed in the benefits list above, you can expect a decrease in phone calls and staff documentation time, and an increase in overall patient satisfaction, compliance, and revenue.   

Our program is turn-key and requires no upfront financial investment – we invoice based on services performed and billed. To begin the program, we identify eligible patients and contact them to enroll. Patients are educated about the program, including potential out of pocket cost, and must provide consent to join. Care managers conduct customizable assessments and institute a care plan for each chronic condition. Following each month of CCM activities, the CCM summary is uploaded directly into your EHR. Charge entry and/or claim billing can also included, depending on your billing setup.   

A successful CCM program is a true partnership between the CCM team and the practice. We strive to provide a valuable benefit to patients and to tailor the program to accommodate practice preferences for documentation and communication. Promoting and recommending the program internally to patients will significantly increase utilization and long-term participation.