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11 Features of the Best Chronic Care Management Companies

Jon-Michial Carter
Written by Jon-Michial Carter

Properly implemented Chronic Care Management (CCM) programs have transformative implications on patient clinical outcomes and healthcare practice revenue. However, without the assistance of a Chronic Care Management company, many practices struggle to achieve adequate enrollment, manage patient churn, and maximize revenue opportunities. 

Selecting the right CCM company is a crucial decision for healthcare providers aiming to enhance their patients' quality of care. With the proliferation of CCM providers in recent years, making an informed choice that best aligns with your healthcare practice's specific needs and priorities is essential. 

To navigate this decision effectively, you must consider a CCM company's experience, range of services, technological capabilities, and commitment to patient enrollment, engagement, and education. Chronic Care Management programs require rigorous documentation and archiving, marketing expertise, infrastructure support, and scalability to thrive.  

This guide explores the benefits of a CCM partner for patients and providers and the key factors to consider when choosing the best CCM company for your practice. We will also explore how ChartSpan’s turnkey, full-service CCM program can help your practice deliver extraordinary care to your patient population. 

What are Chronic Care Management companies?

Chronic Care Management companies assist healthcare providers in managing a CCM program and delivering comprehensive care to Medicare patients with two or more chronic conditions. These companies increase patient engagement through outreach and education, improve patient outcomes by emphasizing preventative care and proactively identifying care gaps, and facilitate seamless care coordination. 

CCM company services

Full-service CCM companies specialize in assisting patients with their needs between clinical visits. They offer patients a wide array of services, including medication refills, transportation arrangements, wellness plan adherence, and appointment scheduling assistance. CCM companies help enrolled patients self-manage their conditions, assess the progression of patients’ illnesses, and address patients’ physical and emotional health on a monthly basis. 

Every patient enrolled in a CCM company’s program receives a monthly call from a care team coordinator. These calls engage patients in an ongoing dialogue about their health. Topics covered on monthly CCM calls include: 

  • Assessing the patient’s physical and mental health
  • Drawing up care goals
  • Discussing their wellness plan and medications
  • Addressing Social Determinants of Health
  • Documenting any new or worsening symptoms or obstacles the patient may encounter. 

CCM companies also offer healthcare providers an additional revenue stream. Around 82% of Medicare patients qualify for Chronic Care Management, presenting most practices with a wealth of potential participants.

However, many practices struggle to implement CCM without assistance because of its administrative challenges. CCM companies handle patient marketing, enrollment, and retention. They can assist you with quick and seamless billing, ensure CMS compliance, and provide robust analytical reporting. 

A great CCM company will also assist your practice in meeting the necessary criteria to be eligible for CMS reimbursements. For example, CPT code 99490 requires every enrolled patient to receive at least 20 minutes of clinical staff time per calendar month. Trained clinicians employed by CCM companies execute and document these monthly check-ins on behalf of your practice.  

By removing the extraneous workload from your practice, the best CCM companies allow you to do what you do best–provide thoughtful, affirming care to your patients. 

11 features of the best CCM companies

1. Data security

Your Chronic Care Management program should have the highest security standards to protect your patients’ information. At the highest level, you should look for a turnkey program that has achieved HITRUST certification so you are confident that all aspects of your program are following appropriate and up-to-date security measures. 

Programs with HITRUST certifications will ensure security is continuously monitored to protect against bad actors and their attempts to access sensitive health information. Successful data breaches cause financial and reputational risks to providers and compromise your patients’ privacy and security.

Additionally, all technology and processes related to your program will need to be HIPAA-compliant and secure. Effective HIPAA compliance and cybersecurity measures are paramount in the protection of patient health information.

2. CMS compliance

Similar to other healthcare programs, care management services must adhere to a strict and detailed level of compliance required by the Centers for Medicare and Medicaid Services (CMS). Your CCM company’s support staff should be trained in the intricacies of CCM and its respective rules.

Major requirements for this program include determining eligibility accurately, recording patient information, and obtaining patient consent. While there are CMS resources that can support your practice, a CCM company should be able to identify and address the compliance needs of your CCM program so your organization stays compliant.

In addition, CCM programs should have regularly scheduled quality auditing processes to ensure that all phone calls and documentation follow the guidelines CMS has set in place for Chronic Care Management programs. Archiving all CCM enrollment and clinical calls for 10 years is one of the most important features of a well-run CCM program and will help you pass compliance audits. The best CCM companies have the technological structure in place to easily and securely preserve these calls for your practice.

3. High patient enrollment

Though often underappreciated, the enrollment functionality of your CCM program is one of the most crucial elements to the program’s success. You will need a team of trained professionals to call your eligible beneficiaries with multiple chronic conditions, educate them on the benefits of the program, and encourage them to enroll.

While this may seem like a simple ask, it's far more complex if you want to maximize your CCM program. These trained professionals need to inform patients about their out-of-pocket costs for enrollment and obtain patient consent. In addition, they should have the skillset to encourage enthusiasm and enrollment in the program. Your practice’s clinical staff may not have the required background to be effective at enrollment.

Without these capabilities, your CCM patient population will likely be much smaller than projected, and you won’t be able to cover the start-up expenses of your program. A valuable CCM partner company will provide robust marketing support, resulting in strong enrollment numbers. For example, ChartSpan’s CCM program boasts an average of 45% enrollment for eligible Medicare beneficiaries.

4. Effective patient marketing

Effective patient marketing is crucial to achieving and maintaining high enrollment. When patients are aware of a program and the features offered, they're more likely to take full advantage of the services available. 

Any CCM company you partner with should have the resources to earnestly educate patients about your services before asking them for their consent to enroll. You should partner with an experienced CCM company that can confidently articulate the value of CCM enrollment to your patients.

5. Net Patient Churn Management

Since enrollment is an ongoing function of Chronic Care Management services, your care management services will also need to be data-intensive so that you can manage patient churn efficiently. Every day patients can:

  • Age into Medicare, making them eligible for enrollment
  • Code a second chronic condition, making them eligible for enrollment
  • Choose to unenroll from the program
  • Expire from the program

Without the ability to closely manage churn data, you will not maximize your results and your program can quickly become disorganized and ineffectual. Unfortunately, almost all practices average negative Net Patient Churn (NPC) in their CCM program, ultimately leading to its dissolution. 

Partnering with a CCM company that provides data reconciliation, eligibility verification, and educational campaigns is essential to managing patient churn and achieving optimal profitability from your CCM endeavor. CCM companies should also assess patient satisfaction to determine how well the program supports people's needs and where it can improve.

6. Clinical interoperability

Interoperability refers to two or more systems sharing information to create a fully integrated system. In the clinical space, interoperability is essential across platforms to ensure all relevant patient data is shared. In the absence of clinical interoperability, coordination falters, information gets lost, and patients are more likely to receive suboptimal care. Patients with chronic conditions are at an increased risk of experiencing poorly coordinated and higher-cost healthcare due to incomplete or missing information.

Chronic Care Management companies should provide a CCM program and platform that integrates with your electronic health record (EHR). This allows all care providers to stay connected to patient updates and program adjustments, ensuring everyone is on the same page regarding a patient's wellness journey. This communication between platforms is critical for managing health risks and improving care outcomes.

Clinical Interoperability

7. Analytical reporting and support tools

Healthcare practices often face a daunting workload and a shortage of resources without the added complexity brought on by monitoring a CCM program. This makes it difficult to devote the necessary time to dig into the details of your program. A successful Chronic Care Management program should be outfitted with robust analytical tracking and reporting. 

There are numerous metrics to monitor and review diligently. These include clinical utilization, inbound and outbound call SLAs, and dozens of other essential performance benchmarks.

Partner with a CCM company that can provide your practice with analytical reporting tools, dedicated client success representatives, and a customer support team. Invest in a CCM company that will not only protect and preserve your data but also use insights from the gathered data to improve processes and performance perpetually. 

8. Easy, automated billing

Setting your billing team up for success will reduce headaches and maximize your reimbursements for CPT 99490. It's important to partner with a CCM company that can easily automate the billing process for CCM claims. 

If you have hundreds of enrolled patients, this pace is neither sustainable nor scalable. The key to easy billing is a data exchange between your Practice Management System (PMS) and your CCM software that can file claims automatically with a few clicks. Removing this responsibility from your clinical staff will free up time and resources for other critical processes.

9. Skilled clinical team

The care coordination team is the heart of any CCM program. They are responsible for connecting with your enrolled Medicare beneficiaries and helping them manage their chronic diseases through preventative care. Their work includes monthly follow-ups with patients, collaborating with patients on comprehensive care plans, and handling patient inquiries. 

Because the care team is an extension of your practice, it’s invaluable that any CCM partner you choose represents your organization as you would. It is crucial to select a CCM company that can provide top-tier care coordinators with the clinical experience, empathy, and communication skills to make your program successful. 

10. Quality Improvement services

Top-tier CCM companies offer their clients complimentary Quality Score Improvement services to help their clients maximize revenue opportunities. They can integrate activities into your care management program that boost MIPS scores, leading to higher reimbursements. Your CCM company can  also assist you in maximizing revenue from your Medicare Shared Savings Program or alternative ACO by ensuring your patients are properly counted as attributed beneficiaries.

Choose All-in-One CCM Solutions From ChartSpan

11. Ongoing training and support

Your CCM company’s customer support team should do more than just track your program’s metrics. They will need to be your first line of contact when it comes to any situations that arise or questions you may have. They should also be responsible for fully training your team during the program’s initial launch and continuously offering support, feedback, and insight throughout your partnership. Close communication between you and your CCM company’s team is crucial for a successful partnership.

Learn more: The key questions to ask when choosing a CCM vendor.

What are the benefits of Chronic Care Management companies?

CCM companies aid practices in efficiently managing their Chronic Care Management programs, leading to enhanced clinical outcomes, fewer unnecessary hospitalizations, reduced healthcare costs, and a better quality of life for enrolled patients. Additionally, they help make it possible for healthcare providers to earn an extra revenue stream by providing CCM services and eliminating the need for complex in-house operations or recruiting and training more staff. CCM companies manage patient marketing and enrollment, ensure all data collected is CMS-compliant and properly archived, and help optimize quality improvement scores. 

How do CCM companies benefit patients?

  • High-touch, monthly communication with every enrolled patient  
  • Ongoing patient education about conditions
  • Patient engagement and activation
  • Care planning services
  • Care coordination between healthcare providers and specialists
  • Medication management, refills, and delivery services 
  • Appointment and transportation scheduling
  • Connecting patients with community resources like food banks, social groups, and financial assistance
  • Reduction of hospitalizations, duplicated tests, and healthcare costs

Learn more: Patient-Centered Care Explained

How do CCM companies benefit providers? 

  • Provide an ongoing revenue source through CMS reimbursements
  • Maintain quality assurance and reporting
  • Manage marketing, enrollment, and patient churn
  • Enhance quality scores for programs like MIPS
  • Ensure CMS compliance
  • Routinely perform and pass quality audits 
  • Allow providers to increase the scale of their CCM programs without additional onboarding or hiring
  • Stop patient conditions from degenerating through preventative care and closure of care gaps
  • Improve patient satisfaction, resource utilization, and clinical outcomes 

Learn more: How to add an additional revenue stream through CCM.

How a CCM company can help you achieve your CCM goals 

ChartSpan’s full-service CCM partners with your practice to deliver extraordinary care at every step of the process. Our compassionate and knowledgeable care team monitors patient progress through monthly calls and connects patients to vital resources like transportation services, medication management assistance, and appointment scheduling. 

Our 24/7/365 nurse hotline ensures no patient is alone, regardless of day or hour. We assist patients with adhering to their comprehensive care plans, help enrolled patients save an average of $240 annually, and see an average 20% reduction in hospitalizations. 

Our effective patient marketing strategies result in an average of 45% patient enrollment in CCM programs. And with just 300 enrolled patients, we can increase your annual recurring revenue by over $100,000. 

Through ChartSpan, billing is simplified and expedited through our proprietary RapidBill™ technology. All patient records are also safely archived for 10 years, keeping your program CMS-compliant and prepared for audits. 

We also provide our clients with a complimentary dedicated quality consultant to help maximize quality scores and discuss any questions they may have about the program. We can help MSSP, ACO, and MIPS participants. To qualify for the MIPS bonus pool reimbursement, practices must achieve a score of 75. The median ChartSpan client achieves a MIPS score of 94, with almost 40% of our customers achieving a perfect score of 100.

CCM software vs. full-service CCM companies

What is CCM software? 

Third-party CCM software offers EHR-integrated platforms that keep all your CCM information in a centralized location. These software services offer the building blocks to track patient data and review program analytics, all while keeping full control of the CCM operation within your hands. 

However, CCM software will not provide your practice with the staffing and infrastructure to support your program. If your practice has no experience in previously managing a CCM program, you may be unprepared to handle its complexities with a software solution alone.  Your practice will be responsible for hiring and managing additional staff members to handle patient enrollment, monthly patient calls, net patient churn, and quality score optimization, among other tasks. 

While CCM software is often more affordable upfront, it is significantly limited in its scope of offerings. CCM software will require more out-of-pocket expenses in other areas, like labor costs and infrastructural investment. The scalability of the program is also limited by the resources of your practice.     


  • Equips your practice with the essential technological tools for analytical tracking and documentation archival
  • Provides a platform for you to analyze patient data and manage patient care
  • Keeps all CCM information in a centralized hub
  • More affordable than fully-managed CCM services 
  • Grants your practice full control of the CCM program


  • More limited in offerings than full-service CCM
  • Increased labor costs, as you will need to hire and train additional staff to handle patient enrollment, marketing, and monthly outreach
  • Program scaling is limited by your practice’s resources
  • Implementing new technology requires additional training for your team
  • Lack of human connection

What is full-service CCM?

Full-service CCM companies function as an extension of your healthcare practice. These companies have trained teams dedicated to patient marketing, enrollment, maintaining CMS compliance, and billing assistance. They also add a distinct and invaluable element of human connection to your CCM program, as they provide nurses and care coordinators who are specially trained to conduct monthly conversations about care planning, care coordination, and self-management with your patients. 


  • Access to a greater range of services (like billing assistance, nurse care hotlines, dedicated quality improvement representatives, etc.) 
  • Unlimited program scalability for greater revenue  
  • No need to hire, train, or manage additional staff to handle the increased volume of work
  • Wealth of experience in areas like CMS compliance and billing 
  • Pre-existing infrastructure already in place to handle outbound calls, analytics tracking, and documentation
  • Human connection that serves to build trust and improve satisfaction
  • Savings on  time, labor costs, and practice resources  


  • More expensive than CCM software 
  • Healthcare practices must work closely with their CCM company
  • Practices have less control over the CCM program than managing it through software

Full-service CCM programs are more expensive initially, but they save practices precious time and money by reducing labor and infrastructural costs. Additionally, these companies can scale the size of the CCM program to meet the demands of your practice, without requiring any additional work from your staff.

Learn more: Software vs. full-service CCM service provider 

Partner with ChartSpan for an exceptional Chronic Care Management program

ChartSpan is an industry-leading facilitator of comprehensive, effective Chronic Care Management services. We believe that proactive patient engagement and timely interventions are critical to achieving better health outcomes for patients managing chronic illnesses. 

However, we also recognize that healthcare practices face a shortage of resources, time, and staffing, which can complicate care management administration. ChartSpan is committed to bridging this gap by providing practices with fully managed care coordination, outreach, and regulatory adherence and documentation. 

ChartSpan relieves the hefty workload CCM implementation places on the shoulders of healthcare practitioners. Our talented internal team manages patient marketing, enrollment, and churn, all while maximizing revenue opportunities for your practice. From patient onboarding to billing automation, we are here to offer assistance at every step of the CCM journey. 

Through ChartSpan’s CCM program, your practice deepens patient loyalty, promotes positive clinical outcomes, and earns new revenue streams. Our compassionate and skillful clinical team is ready to assist patients with a range of challenges, including identifying gaps in care, facilitating lab test access, and arranging medication delivery. 

As we work in tandem with your practice and staff, both you and your patients will reap the rewards of investing in a Chronic Care Management company. Talk with an expert today and learn how ChartSpan can elevate your practice’s care and increase revenue through Chronic Care Management.

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