The Ultimate Provider’s Guide for Implementing Chronic Care Management

December 30, 2020 /

implementing chronic care management

Providing healthcare to a vast population of patients is a difficult task when everyone has different needs. While you may only have to see healthy adult patients once a year, others, especially elders with chronic diseases, typically need more attention. Providing a care coordination program for these patients, like Chronic Care Management, is becoming increasingly popular as preventative and value-based care is at the forefront of provider’s minds. But how can providers ensure their CCM services drive results? The key is to make sure the implementation of your program masters the operational complexities and specific, detailed processes required. Read on to explore the best practices for implementing a successful Chronic Care Management program. 

Follow Each Step in a Proven Yet Complex Process

Data Analysis 

The first step to implementing a Chronic Care Management program is arguably one of the hardest – constructing and refreshing your list of eligible patients. CMS provides us with very clear guidance regarding patient eligibility and standards for compliance. So, one would think that identifying those patients would be straight-forward. Unfortunately, the complexities of each electronic health record (EHR) make it much more difficult. You will need to use your reports to reconcile missing demographic and clinical data, which is often complex and time-consuming. In addition, there are certain circumstances that make a patient ineligible – these are important to understand to avoid billing for patients who will be denied. 

Eligible patients must first be enrolled in Medicare or Medicare Advantage. They must have seen a healthcare provider in the last twelve months and have two or more approved chronic conditions. These conditions must place the patient at significant risk of death, exacerbation/decompensation or functional decline and will last until the death of the patient. A few common chronic conditions are diabetes, arthritis, hypertension and COPD.

You will need an expert in creating custom reports from your EHR for this first step and someone that can refresh these lists on a recurring basis since patients organically age in and flow out of Medicare every day.

Patient Education

Branding and awareness are pivotal to setting up your program. In order for a patient to embrace such a service, significant effort goes into using multiple methods of patient education. If uninformed of the benefits, eligible patients may shy away from your program altogether. It’s important to advertise in-office with marketing materials such as posters and brochures so that patients recognize the program. In addition, reach out to them directly through mediums like email, direct mail and voicemail messaging. This will greatly improve the experience when you first have a conversation about enrollment. In addition, you’ll need to educate your newly enrolled patients with collateral that they can keep for reference, like a welcome packet or brochure to keep in their home. Keep in mind, enrolling patients never ends and is an ongoing cycle because of the organic nature of patients flowing in and out of Medicare.


Enrolling your patients is the next most difficult aspect of running a successful Chronic Care Management program. It requires that every eligible patient is contacted about the program and asked if they would like to join. Medicare requires that you obtain patient consent – either written or verbal – that must be documented in the patient’s medical record.

Medicare requires that each patient is informed of any expected cost-sharing or copay. Typically, a CCM patient must pay a small coinsurance (in most cases, this equals $8 per month) each calendar month to remain in the program. However, if their copay amount is larger, their likelihood to enroll and remain in the program drops dramatically. Coinsurance requirements are the biggest hurdle to enrolling and retaining patients in your CCM program. That’s why it’s important to have accurate copay information for each patient and to have trained specialists who know how to provide compliant rebuttals for patients who are weary of paying a monthly copay.

Most importantly, enrolling patients is not a one-time event. You will need to manage patient churn daily and work hard to consistently offset patients who churn-out of your program, with fresh patients. Otherwise, your program will eventually cease to exist.


The clinical team that administers your CCM program, whether that is clinicians, nurses, or other health care professionals, is required to spend and document 20 meaningful minutes of clinical staff time for each enrolled patient, per month. These 20 minutes can be spent speaking with the patient, educating them on self-management of their health conditions, and other meaningful work. Meaningful work does not have to involve speaking to the patient directly and can include activities such as organizing reports and data from specialists into the patient’s care plan or reconciling patient prescriptions while searching for optimal pricing for medications. Care plans should be accessible to the patients and their current health care providers, including primary care physicians and any specialists, at any time.

Patient care and management of chronic diseases should be the core focus of your Chronic Care Management program. You’ll need to attend to your enrolled patient’s physical and psychosocial needs in a proactive manner to prevent their conditions from worsening – that is the ambition of a CCM program. This will require proactively reaching out to patients, asking open ended questions, and setting goals as a plan of action. In addition, your program’s care coordination team is required to provide 24-hour support, 365 days of the year to your enrolled CCM patients.

Additionally, your care coordination team will need to address social determinants of health for your enrolled patients. Social determinants are critical components of value-based care because they allow providers to oversee a holistic view of their patients’ health and identify areas of well-being that may contribute to future negative outcomes.


Chronic Care Management services (CPT 99490) can only be billed under one provider, once per month. It’s important to have an organized and efficient system in place for CCM billing so that you can receive your reimbursements as quickly as possible. Best practice is to bill across the month versus the end of the month as Medicare typically processes and expedites reimbursement in a predictable 10-14 day turnaround when claims are submitted properly. Billing for CCM does add workload to your billing team, but an automated billing integration lessens the workload dramatically. Without an integrated billing function, you should be prepared to support the billing team until they create efficient workflows as you establish the program.


Monitoring and ensuring the quality and compliance of your CCM program is a critical function. This includes quality assurance of all patient calls, documentation, patient satisfaction, and audits. You must rely on state-of-the-art telephony infrastructure and should deploy a call recording system for quality assurance and auditing purposes that archives calls for 10 years, for CMS audit purposes. In a program meant to serve patients who need it most, quality is a necessity. Without these checks in place, you will not be able to effectively respond to patient inquiries. Providers will likely request to listen to recorded calls and see evidence of the interactions with your patients as they field patient questions. Lastly, if Medicare requests information or demands an audit, data and documentation will be your saving grace.

Work with a team who is built for this!

In summary, providing an effective and compliant in-house CCM program shows a deep commitment to ensuring your patients have a network of support available to them to help manage and maintain their health. However, it requires an investment of time and resources which can deplete your bottom line. For some, the infrastructure investments required for staff to manage the program outweighs the revenue earned. Outsourcing to a partner that specializes in Chronic Care Management is worthy of consideration assuming your objective is to ensure your patients are properly supported and you wish to maximize your program results. With years of experience, ChartSpan is the leading provider of turnkey CCM solutions. If you are interested in learning more about implementing a CCM program at your practice and how we have successfully served over 80,000 patients visit

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