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The Hidden Costs of In-House Chronic Care Management

Chronic Care Management (CCM) has emerged as a foundational strategy for practices looking to improve outcomes, support patients with multiple chronic conditions, and unlock new streams of recurring revenue*. The benefits of the Medicare Chronic Care Management model are clear. Offering CCM to your patients can yield better patient outcomes, decrease hospitalizations, empower patient self-management, improve patient quality of life, and reduce healthcare costs.

But for practices considering building a CCM program from within, the reality is far more nuanced. What begins as a clinical initiative can quickly transform into an operational burden, draining time, staff, and financial resources. Many of the costs associated with in-house CCM implementation aren’t obvious at first glance. They accumulate over time, silently affecting your practice’s efficiency, scalability, and ability to maintain compliance.

Fortunately, there are several ways to mitigate these complexities and support your patients through CCM. While managing a CCM program in-house is a viable option for some practices, others prefer to collaborate with a full-service partner. 

To clarify your decision on whether and how to offer CCM, you must first understand what resources your practice requires to support the program on your own, including the hidden costs, and how the in-house approach compares to the partner alternative. In this guide, we’ll provide specifics about how to support CCM internally and when to consider outside help.

*Results may vary by provider. 

What resources are needed to implement in-house CCM?

By offering CCM to eligible patients, you can help set them on a trajectory to better health. Launching and maintaining a CCM program, however, requires adequate preparation as well as the right supplies and systems. Your practice must have the following resources ready for CCM success.

1. Enrollment staff

Enrollment is one of the most important aspects of a successful CCM program. The Centers for Medicare & Medicaid Services (CMS) require patient consent, meaning you can only bill CCM codes for patients who have voluntarily opted into the program. 

Thus, enrollment staff play a critical role in notifying patients of their eligibility and educating them about the benefits of participating. If patients agree to participate in your CCM program, this team then guides the enrollment process, verifying all requirements outlined by CMS and documenting the enrollment.

The size of your enrollment team will depend on your eligible patient population. As a rule of thumb, plan to commit at least one outbound full-time equivalent (FTE) employee per 100 eligible patients to manage CCM enrollment. 

Although an initial assessment of your eligible patient population can help you estimate reimbursement, recognize that new patients can become eligible for CCM each month. At the same time, previously eligible patients might have a status change that disqualifies them from participating. Enrollment, therefore, is not a one-time event, but an ongoing function. Continuously monitoring your patients to maintain an accurate eligibility record is crucial to maximize your CCM program’s efficacy. If your employees have other responsibilities, this continual process of identifying and enrolling patients can become overwhelming. 

2. Technology

To manage CCM in-house, most practices will need to acquire at least one software solution. Depending on how your practice operates today and your existing tools, you might need to acquire an electronic health record (EHR) as well as additional CCM-specific software. 

Per CMS guidelines, a certified EHR is required for CCM. The EHR is designed to serve as the single source of truth for patient health information. For CCM, an EHR captures patient demographic information, medical history, and CCM services. The communication and data-sharing capabilities of an EHR also make it easier to facilitate key tenets of CCM, including patient self-management and care coordination between providers. 

Although an EHR is essential, it’s often just one part of the technology picture for in-house CCM. While it’s possible to configure your EHR for Chronic Care Management, doing so is not recommended. CCM-related documentation errors can jeopardize the integrity of your entire EHR system, and many EHR systems are not configured to manage all CCM requirements, such as time tracking. 

Likewise, analyzing health improvements over time and patient adherence—to medications, care plans, and appointment schedules—can be challenging without the right tools. Most electronic health records don’t have the robust monitoring and tracking capabilities that CCM requires. Instead, practices that want to manage CCM internally should consider investing in a solution uniquely designed for Chronic Care Management. 

3. 24/7 access

Per CMS, a CCM program must include a care support line with 24/7 access. You must have clinical team members responsible for inbound patient interaction available at all times, including weekends and holidays, to field patient care questions or requests. Practices that are not regularly open around the clock might find achieving that availability challenging. Alternatively, the office may choose to work with a clinical on-call service or local hospital to cover this requirement, which represents an additional cost. Reliable Chronic Care Management partners will have a 24/7 care line built into their services. 

4. Clinical support

CCM is focused primarily on what happens between face-to-face visits. The program encompasses a wide breadth of support services that require clinicians to speak to patients on outbound as well as inbound calls. To offer CCM in-house, you will need at least one outbound clinical FTE employee per 100 enrolled patients. These employees are often called care managers. 

Care managers are responsible for crafting personalized care plans and escalating timely concerns to providers. They also manage monthly touchpoints with patients, supporting them as needed with appointment scheduling, medication refills, and community resources, such as transportation and food resources, when Social Determinants of Health (SDOH) present a barrier to care. 

Care managers should also identify gaps in care, or have a dedicated quality team who can help them identify those gaps. Care managers can then address care gaps through proactive communication and care coordination. They may offer assessments and screenings, adjust care plans, or gather records from other providers. 

5. CMS compliance

In-house CCM programs must be prepared to manage nuanced documentation and billing requirements with meticulous attention to detail. This requires not only a deep understanding of the CMS requirements themselves, but also of the processes and infrastructure to support data collection, monitoring, and analytics.

For example, you must be prepared to record and archive all patient enrollment calls or written enrollments. You must also track time spent on care for each patient, each month before billing for CCM. 

Providers must recognize that CCM requirements may disrupt their existing billing practices and workflows. Before launching a CCM program, internal leaders must gain the expertise to architect systems that support Chronic Care Management if they are not already in place. 

Improper use of the Chronic Care Management CPT codes will disrupt reimbursement and could jeopardize your ability to offer CCM to your patients. 

Hidden costs of an in-house CCM program

In addition to the overt costs associated with each of the resources needed for CCM, many practices encounter other hidden costs related to starting or maintaining a CCM program. Be mindful of these possible expenses of managing a CCM program internally. 

Significant time & labor investment

Adding additional responsibilities to existing team members is an option; however, hiring dedicated CCM staff is often a more sustainable choice. Overworking your staff can lead to higher rates of turnover, lower team morale, burnout, and reduced productivity—all of which increase employment costs. Balance cost and sustainability when architecting your CCM support infrastructure.

Program support activities are also time-intensive, requiring significant human capital. Time spent on CCM might not directly translate to costs. However, you should consider whether the time spent on CCM might be spent on other vital elements of patient care. 

Training & onboarding

Whether you bring in new hires or train your existing staff, recognize that there may be a period of “downtime” where your team is learning the CCM requirements and putting systems in place to deliver a high-quality experience to your patients from the start.

Enrollment volume

Full-time staff represent an ongoing cost. However, depending on the size of your practice and eligible patient volume, CCM-related revenue might not be as consistent. Many practices find that to support the internal staff needed for CCM, they need to enroll a very high number of CCM patients. 

Patient marketing

With an in-house CCM program, your practice is responsible for driving patient awareness and enrollment. That means you’ll need to create or source all the necessary collateral—social media content, brochures, email campaigns, and other outreach efforts—to inform eligible patients about the program and encourage participation. This requires both time and marketing expertise, as well as potential costs for design, printing, and distribution.

Contractor fees

If you can’t fulfill the 24/7 access to care CCM requirement, you’ll need to factor in the cost of an external solution. This might include a clinical hotline service or partnership with another healthcare facility that can cover the hours your office is closed. 

Implementation

For both EHR and CCM software, expect an implementation period during which staff are training on the digital tools, relevant systems are connected, and any technology bugs are addressed and resolved. Depending on the scope of the installation, implementation can interrupt “business as usual” in the clinic and may present a steep learning curve that reduces productivity temporarily. 

Ongoing fees

Most software requires an initial investment plus recurring maintenance or support fees. SaaS solutions typically work with an ongoing monthly subscription. When assessing technology cost, consider both one-time and ongoing expenses for an accurate estimate of the expense.

What are the advantages of in-house CCM?

There are a few advantages to managing CCM in-house, particularly for well-staffed practices with relatively few CCM-eligible patients. For such providers, managing CCM internally can mean: 

• Unmediated patient communication 
• Direct, internal involvement in patient care
• Greater continuity of care
• More in-person program oversight
• Minimal staff needed for small eligible patient populations

What are the disadvantages of in-house CCM?

While in-house CCM programs may enjoy more in-person oversight and connections between practice staff and patients, managing a program in this way also comes with some drawbacks. An internally staffed approach may result in greater risk, upfront investment, and time to start than collaborating with a partner. 

• Significant upfront investment 
• Long startup period, due to the need for training and new workflows
• Significant compliance burden 
• Reduced scalability 
• Staffing responsibility 
• Reduced enrollment rates 

Practices must determine to what extent they value independence versus risk and a steeper learning curve. In many cases, partnering with a full-service CCM provider like ChartSpan reduces the cost and logistical burden of a complex program like CCM.

Questions to ask before pursuing an in-house CCM program

Before implementing a CCM program with your internal resources, consider these critical questions first. 

1. Can our existing staff support the demands of CCM, or do we need to hire? 
2. What investments do we need to make in technology to support CCM? 
3. How will we support the requirement for around-the-clock access to care? 
4. How many CCM-eligible patients do we serve? 
5. Can we realistically achieve the compliance requirements of CCM in-house? 
6. Will we be able to cover CCM costs with the anticipated revenue from the program? 

Generally speaking, practices with 100 or fewer eligible CCM patients might be better suited to an in-house approach than those with a larger volume of qualifying Medicare patients. 

Collaborating with a full-service CCM partner as an alternative

Managing a CCM program on your own isn’t the only way to tap into the benefits of Chronic Care Management and improve the quality of care you provide your patients. You can also work with a CCM partner, like ChartSpan, who can manage the compliance and logistical aspects of a CCM program, while complementing your clinical expertise and patient relationships. 

Many practices, especially those with large CCM-eligible patient populations, find that the advantages of collaborating with a partner far outweigh those of in-house program management. 

Benefits of working with a fully-managed CCM partner 

• Time savings: A CCM partner can offer tremendous time savings for your practice. For a health system serving 500 CCM-eligible patients per year, you could enjoy up to 327 hours in time savings each year. With that time, your team has the freedom to focus on other activities that improve patient care. 
• Large-scale efficiencies and learnings: Working with a partner allows you to benefit from learnings gleaned from hundreds of CCM programs and patients across the country. ChartSpan, for example, serves more than 175 practices and health systems and counting. 
• Compliant processes: Understanding CMS requirements for CCM is critical. By collaborating with a partner, you can have peace of mind knowing all the workflows, processes, and technologies are already in compliance. ChartSpan partners receive the documentation to support accurate billing for CCM services. 
• Fully staffed: A full-service partner, such as ChartSpan, acts as an extension of your internal team. By collaborating with a vendor, you don’t have to worry about hiring or training new staff. Instead, the partner takes on the burden of supplying the right personnel to support CCM.
• Enrollment expertise: Enrolling eligible patients can be the hardest part of getting your CCM program off the ground. By working with a full-service partner, you benefit from specialized enrollment expertise. Often, this knowledge and experience translate to higher enrollment rates. For example, our partners achieve 45 percent patient enrollment, on average, for eligible Medicare beneficiaries.*
• Scalability: CCM vendors tend to offer greater flexibility to scale up or down quickly, compared to an internally-staffed approach. With more resources at their disposal, partners can adjust their teams and processes as needed. 

*Results may vary by provider. 

The ChartSpan approach to full-service CCM partnership 

If you determine a partner approach makes the most sense for your practice, you need to choose the right vendor. ChartSpan’s comprehensive CCM offering enables our partners to focus on care delivery and improve care quality, without the administrative burden of implementing a CCM program in-house. 

Tailored approach to enrollment

We know that every practice is different. Instead of a copy-and-paste solution, we take the time to understand your unique patient population and preferences. Our team of enrollment specialists, quality experts, and administrators assesses the right strategies to yield the highest enrollment rates. Our diverse experience includes working with specialists, primary care practices, Federally Qualified Health Centers, Rural Health Clinics, and large health systems. 

Effective patient education material

Your CCM program is only effective if it reaches eligible patients. Our educational materials speak clearly to the value of your CCM program. Thus, we empower your patients with the information they need to enroll confidently.

Once they’re enrolled, patients receive a personalized call from their care manager as well as a detailed welcome packet with important contact information and answers to common questions. As experts in the enrollment process, we also manage the constantly evolving list of eligible patients, ensuring your program remains compliant with CMS regulations and captures the greatest percentage of eligible patients. 

Dedicated care managers

Effective healthcare is built on a foundation of trust. ChartSpan care managers work to develop ongoing relationships with patients, which improves patient engagement, boosts health outcomes, and helps patients feel well-supported within your CCM program. 

Our experienced clinical team is knowledgeable about CCM-specific requirements and well-equipped to manage clinical support. From appointment reminders and medication refills to patient education, assessments, and SDOH support, our care managers have a multitude of tools at their disposal to guide patients toward better health. 

Designed to scale

Whether you’re implementing CCM for the first time or ready to expand your program, ChartSpan offers the flexibility to meet your practice’s unique needs. With the personnel, workflows, and resources at our disposal, scaling your program up or down to meet patient demand is straightforward and efficient. 

CMS-compliant processes

We’re experts in CCM, so we understand the unique CMS requirements, and we’ve designed our processes and systems around them. For our partners, that means peace of mind that they’re not alone in managing compliance. We document and report the appropriate information for every patient in our program, enabling your practice to bill accurately and confidently. We’re constantly monitoring the value-based care landscape to help you understand and get ahead of any changes that might affect the success of your CCM program. 

Ultimately, choosing an in-house approach versus a partner approach comes down to a combination of your patients, team, and preferences. Whether you’re a large practice serving many thousands of patients or a smaller practice with only a few CCM-eligible patients, you can access the compelling advantages of CCM within your model of care. 

Interested in offering better, more personalized care for your patients through CCM? Learn how our fully-managed approach to Chronic Care Management simplifies program implementation and improves the level of care you’re able to deliver. 

You might also like:

• A Comprehensive Medicare Audit Checklist for Your Care Management Program
• Value-Based Care Programs – Which Ones Deliver Results?