Your patients with multiple chronic conditions often feel like they're navigating their health journey alone. They juggle appointments with different specialists, manage complex medication schedules, and face daily uncertainty about their health. A Chronic Care Management (CCM) program acts as their dedicated support system, providing a consistent point of contact and a safety net between office visits. By offering proactive monitoring, medication management, and on demand access to care support, you can help them feel more confident and in control. This guide explains how implementing a CCM program can transform the patient experience, leading to better health outcomes, fewer hospitalizations, and stronger, more loyal relationships with your patients.
Chronic Care Management, or CCM, is a healthcare service that provides ongoing care and support for patients with multiple chronic conditions. Think of it as the connective tissue between office visits. The goal is to help patients proactively manage their health, improve their quality of life, and reduce complications and hospitalizations. For your practice, it’s a structured way to provide and get reimbursed for the essential, non-face-to-face care your most complex patients need.
A strong CCM program is built around a comprehensive, personalized care plan. This plan acts as a roadmap, detailing a patient's health problems, treatment goals, medications, and other critical health information. Beyond the initial plan, CCM services include regular monitoring of the patient's health status and ongoing medication management to ensure adherence and prevent adverse effects. It also involves coordinating care across different providers—such as specialists, pharmacists, and community services—to ensure everyone is on the same page. Patient education and support are woven throughout, empowering patients to take an active role in their own health.
Most CCM services happen outside of your regular office visits. It’s the care that takes place over the phone or through digital tools, making it a convenient and consistent touchpoint for patients. To start, your patient provides consent to receive these services each month. Once they agree, your team creates their personalized care plan. The American Academy of Family Physicians (AAFP) notes that these non-face-to-face services are critical for providing better care and can help lower overall healthcare costs by addressing issues before they become emergencies. It’s a proactive model that keeps you connected to your patients when they need it most.
CCM is specifically for Medicare beneficiaries who have two or more chronic conditions that are expected to last for at least 12 months or until the end of life. These conditions place the patient at significant risk of functional decline or even death. While the list of qualifying conditions is long, some of the most common examples include:
The focus is on patients who require substantial care coordination and management to maintain their health and prevent their conditions from worsening.
It’s not just about the patient’s health status; your practice also needs to meet specific requirements to provide and bill for these services.
Understanding who qualifies for CCM is the first step to building a successful program. The criteria, primarily set by Medicare, are designed to identify patients who will benefit most from continuous, coordinated care. It’s not just about the patient’s health status; your practice also needs to meet specific requirements to provide and bill for these services.
Think of it as a three-part checklist: the patient, the provider, and the conditions. First, the patient must have specific health needs that make them eligible. Second, your practice must have the right infrastructure and processes in place. Finally, the chronic conditions themselves must meet a certain definition of severity and duration. Getting these three elements aligned ensures your CCM program is both compliant and effective, helping you deliver better care to the patients who need it most while creating a new, reliable revenue stream for your practice. Let's break down exactly what each of these qualifications entails.
For a patient to be eligible for CCM, they must have two or more chronic conditions that are expected to last at least 12 months or until the end of their life. These conditions must place the patient at significant risk of death, acute exacerbation, or functional decline. It’s about identifying individuals who require ongoing medical attention beyond a typical office visit.
While CCM is a Medicare-covered service, it’s also reimbursable under most Medicare Advantage (MA) plans and many commercial insurance policies. That means eligibility isn’t limited to traditional Medicare enrollees—your practice can offer and bill for CCM across a broad range of payers, depending on coverage.
Before you can begin providing services, you must also obtain the patient’s consent. This is a critical step. You need to explain what CCM services involve, how they can help, and that only one provider can bill for CCM each month. This conversation ensures patients are active participants in their care plan from day one.
Your practice also has to meet certain standards to offer CCM. First and foremost, you must have a valid Medicare provider number. Beyond that, you are required to use a certified Electronic Health Record (EHR) system to document and manage patient care. This technology is the backbone of a successful CCM program, allowing you to create, share, and maintain a comprehensive care plan for each patient.
This care plan is a central part of your provider requirements. It’s a detailed roadmap for managing the patient’s health, accessible to them and any other providers involved in their care. Your practice must also be able to provide 24/7 access to a member of the care team for any urgent needs, ensuring patients always have a point of contact.
A well-structured CCM program is more than just a series of monthly check-ins. It’s a comprehensive suite of services designed to provide continuous, coordinated care that supports both your patients and your practice. By focusing on proactive management instead of reactive treatment, CCM helps patients with chronic conditions stay healthier and more engaged in their own care. For your practice, this translates to better patient outcomes, stronger relationships, and a more efficient workflow. Let's look at the core services that make a CCM program so effective.
Think of care coordination as the central nervous system of your patient's healthcare journey. It’s the active process of organizing patient care activities and sharing information among all participants. This includes regular communication with patients by phone or email, reviewing their medical records, and coordinating care with other specialists, pharmacies, and community services. For patients with multiple chronic conditions, who often see several different doctors, this service is invaluable. It ensures everyone on the care team is on the same page, preventing conflicting treatments, reducing redundant tests, and closing dangerous gaps in care. This seamless integration is key to managing complex health needs effectively.
Chronic conditions don’t operate on a 9-to-5 schedule. A key component of any CCM program is giving patients access to a qualified healthcare professional 24 hours a day, 7 days a week, for urgent needs. This doesn't mean you have to be on call around the clock. Instead, it involves having a system in place—whether through your practice or a partner like 1bios—to address urgent issues as they arise. This immediate access provides immense peace of mind for patients and their families, often preventing unnecessary and costly emergency room visits for problems that can be managed with timely advice.
A personalized care plan is the foundation of effective CCM. This isn't a static document; it's a dynamic roadmap that outlines the patient's health problems, goals, and treatment strategy. According to the American Academy of Family Physicians, a comprehensive care plan must be created within the patient's Electronic Health Record (EHR) and a copy shared with them. This plan is developed collaboratively with the patient and their caregivers, ensuring it reflects their personal preferences and values. It serves as a central guide for the entire care team, detailing everything from medication schedules to planned interventions and long-term health goals.
For patients juggling multiple prescriptions, medication management is a critical service. It involves much more than just writing prescriptions. A core part of CCM is conducting regular reviews of a patient's medications to ensure they are taking them correctly, checking for potential interactions, and managing side effects. These medication reviews are essential for preventing adverse drug events and improving treatment adherence. This proactive approach helps patients understand their medications better, leading to improved safety and more effective management of their chronic conditions. It’s a simple but powerful way to protect your patients.
Empowering patients to take an active role in their health is a central goal of CCM. This is achieved through ongoing health monitoring and education. Patients are the ones managing their conditions every day, so providing them with the right knowledge and tools is crucial for success. This can involve teaching them how to monitor their blood pressure or glucose levels, explaining the importance of their diet and exercise plan, or helping them recognize symptoms that require attention. When combined with services like Remote Patient Monitoring (RPM), this continuous oversight helps you catch potential issues before they become serious problems.
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Ultimately, the goal of every CCM service is to help people with multiple long-term health problems manage their conditions more effectively. When care is coordinated, accessible, and personalized, patient outcomes naturally improve. Patients become more engaged and knowledgeable about their health, leading to better adherence to treatment plans and healthier lifestyle choices. This proactive model of care helps reduce hospitalizations, emergency room visits, and readmissions. By focusing on keeping patients stable and supported at home, CCM directly contributes to a higher quality of life for those you serve.=
While the patient benefits are clear, a CCM program also offers significant advantages for your practice. It creates a new, consistent stream of recurring revenue that complements your traditional fee-for-service income. Beyond the financial aspect, CCM improves communication and collaboration among all the providers involved in a patient's care, leading to a more cohesive and efficient workflow. By offloading the time-intensive work of non-face-to-face care management, you can focus on in-office visits while ensuring your patients receive the continuous support they need. This strengthens patient loyalty and positions your practice as a leader in comprehensive, patient-centered care.
Many practices attempt to launch CCM internally, only to discover that documentation, compliance, and staffing demands can outweigh the benefits. That’s why a growing number of independent practices are turning to partners like 1bios to provide a fully managed, white-glove CCM solution that integrates with existing workflows, reduces administrative overhead, and delivers measurable clinical and financial outcomes—without adding new staff.
A CCM program can be a powerful tool for improving patient outcomes, but it also needs to be financially sustainable for your practice. The good news is that getting paid for your services doesn't have to be complicated. Medicare and many private payers recognize the value of CCM and have established clear reimbursement pathways. Success comes down to understanding the right billing codes, documenting your work carefully, and staying on top of compliance requirements. Think of it as a simple formula: provide excellent care, document it correctly, and get paid for your hard work. This approach not only supports your patients' health but also builds a new, reliable revenue stream for your practice. Let's walk through the key components to ensure your practice gets reimbursed properly for the essential care you provide.
Since most CCM services happen outside of a typical office visit, they have their own set of billing codes.
Since most CCM services happen outside of a typical office visit, they have their own set of billing codes. The most common starting point is CPT code 99490, which covers the first 20 minutes of non-complex CCM services provided by clinical staff in a calendar month. Additional codes exist for more time spent or for more complex cases. The most important rule is to document everything. Every call, medication review, and coordination effort must be logged in the patient’s electronic health record (EHR). This detailed documentation is not just good practice—it’s your proof of service and the key to successful reimbursement.
Medicare champions CCM because it leads to better-managed chronic conditions, which can reduce hospitalizations and lower overall healthcare spending. As a result, they reimburse providers on a monthly basis for each enrolled patient who receives the minimum required service time. This creates a predictable, recurring revenue stream for your practice—a huge plus for small- and mid-size clinics. It’s important to know that CCM falls under Medicare Part B, which means patients are typically responsible for a 20% coinsurance. This cost-sharing is a standard part of the structure, but as we’ll see, it doesn’t always mean an out-of-pocket expense for the patient.
Compliance is the foundation of a successful and audit-proof CCM program. Before you can bill for any services, you must get patient consent. This agreement can be verbal or written, but it must be documented in their health record. The patient needs to understand that you’ll be providing ongoing management services and that cost-sharing may apply. Beyond consent, meticulous time-tracking is essential. You must keep accurate records of the time your staff spends on CCM activities for each patient. Using a certified EHR to log every minute and every service is the best way to ensure you meet all Medicare requirements and can confidently defend your billing in an audit.
The 20% copay can sometimes be a barrier to patient enrollment, so it’s important to explain it clearly. After a patient meets their annual Part B deductible, they are responsible for 20% of the Medicare-approved amount for CCM services each month. However, many of your patients may not have to pay anything out of pocket. Those with supplemental insurance, like a Medigap plan, or patients who are dually eligible for Medicare and Medicaid often have this coinsurance covered completely. Communicating this to eligible patients can significantly improve your enrollment and participation rates, ensuring more people get the continuous care they need without worrying about the cost.
Launching a CCM program is a powerful way to improve patient care and create a new, recurring revenue stream for your practice. But getting started can feel like a huge undertaking—especially when you’re already short on time and staff. From patient enrollment and staff training to time tracking and billing, there are a lot of moving parts to manage. The good news? You don’t have to do it alone. While the steps below outline what’s required, many practices choose to partner with a turnkey provider like 1bios to handle the heavy lifting from day one.
By focusing on five core areas—staff training, technology, patient enrollment, workflows, and data management—you can build a successful and sustainable CCM program from the ground up. Whether you do it yourself or lean on a partner, these foundational steps will put you on the right path to providing excellent chronic care while supporting your practice’s financial health.
Train your staff for success
Your team is the heart of your CCM program, so their preparation is critical. Start by clearly defining roles and responsibilities. Who will be the primary point of contact for patients? Who is responsible for tracking time and documenting care? Everyone involved, from medical assistants to physicians, should understand the program's goals and their specific part in it. You’ll need to adjust existing documentation habits and create new workflows to accurately capture the non-face-to-face time that makes CCM unique. Consistent training ensures your team feels confident and your program runs smoothly.
Many clinics simply don't have the budget to hire a dedicated administrator to manage billing and program planning. A good CCM platform automates time-tracking, simplifies documentation, and streamlines billing, which are often the biggest administrative hurdles.
The right technology makes a CCM program possible, especially for smaller practices. Many clinics simply don't have the budget to hire a dedicated administrator to manage billing and program planning. A good CCM platform automates time-tracking, simplifies documentation, and streamlines billing, which are often the biggest administrative hurdles. When choosing a platform, look for one that integrates with your existing EHR. The goal is to find a CCM solution that reduces your team's workload, not adds to it, so you can focus more on patient care and less on paperwork.
A CCM program is only valuable if your patients participate. The first step is identifying eligible patients within your practice—those with two or more chronic conditions. From there, the focus shifts to education and consent. Many traditional outreach methods, like leaving voicemails, are ineffective. Instead, have a direct conversation with patients about the benefits of CCM, such as 24/7 access to care and personalized support. Explain any potential co-pays and be sure to obtain and document their verbal or written consent before providing any services. A clear, empathetic approach builds trust and encourages enrollment.
A smooth administrative workflow is the backbone of a compliant and profitable CCM program. This means creating a standardized process for every step, from the moment you obtain a patient's consent to when you submit a monthly claim. Your workflow should clearly outline how your team will create and update care plans, document at least 20 minutes of non-face-to-face service each month, and coordinate with other providers. By standardizing these tasks, you minimize the risk of errors, ensure you meet all Medicare requirements, and make the entire process more efficient for your staff.
Effectively managing your CCM program requires tracking key data. This isn't just about billing; it's about understanding your program's impact on both patient health and your practice's bottom line. Given that many practices struggle with insufficient time and resources, a system that simplifies data analysis is essential. Regularly review metrics like patient engagement levels, clinical outcomes (e.g., lower A1c levels or blood pressure), and total time logged per patient. This information helps you demonstrate the program's value, identify areas for improvement, and ensure you're operating efficiently.
Launching a CCM program is one of the most impactful steps you can take for your patients and your practice. It creates a pathway for continuous, proactive care that can genuinely change lives. But let's be honest—implementing a new program comes with its own set of hurdles. Many practices worry about stretching their staff too thin, keeping patients engaged, navigating new technology, and staying on top of the detailed documentation required for reimbursement.
These are valid concerns, but they are absolutely solvable. The key is to anticipate these challenges and build a strategy to address them from the start. You don't have to create every process from scratch or become an expert in compliance overnight. By leveraging the right partners and technology, you can build a successful and sustainable CCM program that benefits everyone involved, without overwhelming your team. Let’s walk through some of the most common challenges and, more importantly, their practical solutions.
For many small to mid-size practices, the biggest question is: "Who is going to do all this work?" Your team is likely already at capacity managing in-person visits and daily administrative tasks. The idea of adding 20 minutes of non-face-to-face care coordination per patient each month can feel daunting. Instead of trying to hire and train a new internal team, consider partnering with a dedicated CCM service. This approach allows you to offload the heavy lifting of care coordination, patient calls, and documentation to a team of experts. It’s a cost-effective way to launch your program quickly and ensure your patients receive high-quality, consistent support without burning out your existing staff.
Keeping patients consistently engaged is crucial for CCM success, but it’s not always easy. Traditional outreach often involves a frustrating cycle of phone calls and voicemails. To truly connect with patients, you need a more dynamic approach. Combining personalized outreach from a dedicated care manager with user-friendly technology like RPM can make a world of difference. When patients can easily share their vitals from home and know a real person is monitoring their progress, they become active participants in their own health. This consistent connection builds trust and provides the steady stream of data you need to deliver proactive care.
Introducing new technology, especially to older patients with chronic conditions, can be a significant hurdle. Many patients may feel intimidated by remote monitoring devices or patient portals. The solution isn't to avoid technology, but to make it incredibly simple and supportive. Choose a CCM partner that provides easy-to-use, pre-configured devices that work right out of the box. More importantly, ensure they offer comprehensive onboarding and ongoing technical support for your patients. When someone is available to patiently walk a patient through setup and answer their questions, technology becomes an empowering tool rather than a frustrating barrier.
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CMS has strict rules for CCM reimbursement. You must meticulously track every minute spent on care coordination and maintain a comprehensive care plan for each patient. This level of documentation can quickly become an administrative nightmare, leading to billing errors or audit risks. The best way to handle this is with a platform designed specifically for CCM. The right software can automate time-tracking, simplify care plan creation, and generate audit-ready reports. By systemizing your documentation process, you can confidently bill for your services and ensure your practice remains fully compliant, freeing up your team to focus on patient care.
Even if you have the resources to dedicate staff to your CCM program, getting them properly trained is a major undertaking. Your team needs to be fluent in CMS guidelines, billing codes, care coordination protocols, and patient communication techniques. This requires a significant investment in time and education. An effective alternative is to work with a partner that provides a highly trained clinical team as part of their service. This gives you immediate access to professionals who are already experts in delivering and documenting CCM services, allowing you to bypass the steep learning curve and start offering high-quality care from day one.
Implementing a CCM program in-house can feel like a heavy lift—especially for small and mid-sized practices already operating with limited time and staff. That’s why many organizations turn to outside partners to help with key components like patient outreach, care coordination, documentation, billing, and compliance. A well-chosen partner can offload the administrative burden, improve program outcomes, and ensure billing success.
1bios is one such partner. Built specifically for small and mid-sized practices, 1bios offers a true turnkey CCM solution—combining AI-powered technology, experienced U.S.-based care teams, and a compliance-first approach to CCM. From patient eligibility analysis and enrollment to documentation, 24/7 care delivery, and audit-ready billing support, 1bios manages the entire process under one roof.
Practices working with 1bios benefit from:
Higher patient enrollment and engagement, powered by automated outreach and human-led onboarding workflows
AI-enabled care coordination, with tools like the Care Coach that surface patient risks and care gaps
Staff workload relief, by offloading documentation, care plan creation, and check-ins to a dedicated monitoring team
Audit-proof compliance, with every touchpoint, time log, and care activity automatically tracked and stored in the EHR
Aligned incentives, with a performance-based model where 1bios only gets paid when practices do
Because 1bios manages both the technology and the staffing, it offers a unique combination of control, quality, and simplicity—allowing providers to stay focused on in-clinic care while scaling high-quality chronic care support between visits.
Launching a CCM program is one thing, but making it truly successful is another. It requires a thoughtful approach that goes beyond just meeting the basic requirements for reimbursement. A great program becomes a core part of your practice, improving patient health, strengthening patient relationships, and creating a reliable new revenue stream. But this doesn't happen by accident. It involves focusing on the quality of care, ensuring your team works together seamlessly, and communicating effectively with patients.
Success also means being willing to look at your processes, see what can be improved, and plan for future growth. Many practices find that managing chronic conditions is a challenge due to insufficient time and resources. By focusing on a few key areas, you can build a program that not only meets these challenges but also thrives. Let's break down the five pillars that will support a successful and sustainable CCM program in your practice.
The ultimate goal of CCM is to improve patient outcomes, so quality should always be your top priority. Regularly track key metrics like hospital readmission rates, medication adherence, and patient-reported satisfaction. This data gives you a clear picture of what's working and where you need to make adjustments. If your team is already stretched thin, maintaining this level of oversight can feel overwhelming. Partnering with a CCM specialist can provide the dedicated support and detailed reporting needed to maintain high standards of care without adding to your staff's workload.
A successful CCM program hinges on excellent care coordination. This means creating a system where your primary care team, specialists, and any external providers are all on the same page. It involves regular communication and a shared understanding of each patient's comprehensive care plan. When your team is truly integrated, you can prevent gaps in care, reduce redundant tests, and ensure every patient feels supported by a unified front. This collaborative approach is fundamental to delivering the kind of proactive care that defines high-quality CCM.
Consistent, reliable communication is the foundation of patient engagement. Traditional outreach methods often result in a frustrating game of phone tag, which can be a major barrier to success. Instead, establish clear protocols for how and when your team will connect with patients. This could include a mix of secure messaging for quick questions, scheduled check-in calls for in-depth conversations, and educational emails. The goal is to make communication predictable and easy for patients, which builds trust and encourages them to actively participate in managing their health.
Your CCM program shouldn't be a "set it and forget it" initiative. To ensure its long-term success, schedule regular check-ins to assess what’s working and what isn’t. Are your documentation workflows efficient, or are they creating bottlenecks? Does your staff feel confident and well-equipped in their roles? Are patients staying enrolled and engaged? Answering these questions honestly allows you to make small, strategic adjustments along the way. Optimizing your program over time ensures it remains effective for your patients and sustainable for your practice.
Once your CCM program is running smoothly and delivering results, you can start thinking about growth. Scaling effectively means having the right foundation in place to handle more patients without a drop in quality. Before you expand, consider if your current technology can support a larger patient load and if your team has the capacity for increased outreach and documentation. Planning for growth from the beginning helps you avoid common barriers to CCM, like inadequate infrastructure, and ensures your program can expand sustainably for years to come.
Launching a CCM program is a significant first step, but the real success comes from continuous refinement and thoughtful optimization. A great CCM program doesn't just run on autopilot; it evolves with your practice and patients, becoming a seamless extension of the high-quality care you already provide. It’s about moving beyond simply checking boxes for reimbursement and creating a dynamic system that genuinely improves patient health, prevents staff burnout, and strengthens your practice's financial stability. When you fine-tune your approach, you can unlock the full potential of CCM. This means looking closely at how your team works, how patients are engaging, and what the data is telling you. Are patients consistently participating? Is your staff spending too much time on documentation? Is the program delivering the clinical and financial results you expected? Answering these questions is key to building a sustainable and effective program. By focusing on a few key areas—from patient education to performance tracking—you can ensure your program delivers maximum value for everyone involved. The following strategies will help you optimize your CCM services, turning a good program into a truly transformative one that enhances patient loyalty and drives better health outcomes.
Your patients are the most important part of your CCM program, and their active participation is essential. When patients understand why they’re enrolled and how it benefits them, they’re more likely to engage. Take the time to explain that CCM is a partnership designed to give them more support between office visits. Frame it as having a dedicated care team member they can reach out to for questions and guidance. You can empower patients by providing easy-to-understand materials about their conditions and care plan. This helps them feel more in control of their health and transforms them from passive recipients of care into active partners in their own well-being.
A successful CCM program runs on clear communication and well-defined workflows. To prevent staff burnout and ensure consistent care, it’s crucial to establish who is responsible for each task, from patient outreach to documenting time. Create standardized processes for common activities like medication reconciliation and care plan updates. This reduces confusion and ensures every patient receives the same high level of service. Regular team check-ins can also help identify bottlenecks and streamline communication. When your team operates efficiently, they can spend less time on administrative hurdles and more time focused on meaningful patient interactions, which is the ultimate goal.
The right technology should feel like a helping hand, not another administrative burden. Your CCM platform should simplify tasks like time-tracking, documentation, and patient communication. Look for a solution that integrates smoothly with your existing EHR to minimize duplicate data entry and give your team a complete view of the patient’s health history. A user-friendly platform makes it easier for your staff to manage their tasks and for patients to engage with their care team. By leveraging a powerful and intuitive CCM system, you can automate routine work, ensure compliance, and free up your staff to focus on providing excellent care.
To ensure your CCM program is meeting its goals, you need to track its performance. Regularly reviewing key metrics helps you understand what’s working and where you can make improvements. Monitor clinical outcomes, such as reductions in hospital readmissions or improvements in blood pressure control. Keep an eye on operational metrics like patient enrollment and engagement rates, as well as the total care management time logged per month. Finally, track financial performance to confirm the program is generating the expected revenue. Analyzing this data allows you to make informed decisions, demonstrate the program's value, and continuously optimize your services for better patient outcomes and practice health.
A CCM program isn’t just a one-time project—it’s an ongoing operational workflow that affects patient outcomes, provider satisfaction, billing reliability, and long-term sustainability.
Whether you’re managing your CCM program in-house or exploring outside support, it’s worth evaluating your long-term needs. A CCM program isn’t just a one-time project—it’s an ongoing operational workflow that affects patient outcomes, provider satisfaction, billing reliability, and long-term sustainability.
As you evaluate technology vendors, platforms, or service providers, consider the following:
Do they offer end-to-end support? Many vendors only provide software or staffing—not both. Look for a solution that manages everything from enrollment to care delivery to billing, so nothing slips through the cracks.
Is their care team in-house and U.S.-based? The quality of patient engagement depends on the quality of your team. U.S.-based staff who are trained in your workflows can deliver a more trusted, consistent experience.
Do they prioritize compliance and audit-readiness? With strict Medicare requirements and potential audits, your partner should proactively ensure documentation, care plans, and time logs meet every standard.
Can they scale with you? As your program grows, your partner should be able to support higher patient volumes, more specialties, and complex billing scenarios without disruption.
Do they align financially with your success? Ideally, your partner only gets paid when you do—reducing risk and aligning incentives from day one.
1bios was built with all of these priorities in mind. Its fully managed, performance-aligned CCM model ensures practices can confidently expand their chronic care services, knowing they have the tools, staff, and compliance support they need to succeed—today and as the program scales.
That's a great question because it gets to the heart of the program. You're likely already doing a lot of the work, like coordinating with specialists or answering patient calls between visits. Chronic Care Management formalizes that effort. It creates a structured, documented, and billable framework for all the essential non-face-to-face care you provide. Think of it as getting reimbursed for the critical work that happens outside the exam room, all guided by a comprehensive, personalized care plan for each patient.
This is a common and valid concern. While Medicare's 20% coinsurance applies to CCM, many of your patients may not have to pay anything out of pocket. Those with supplemental insurance or who are dually eligible for Medicaid often have this cost completely covered. For others, it helps to frame the service around its value—having 24/7 access to a care team member and dedicated support to help them manage their health at home is a powerful benefit that provides real peace of mind.
To bill for the primary CCM code, your clinical staff needs to provide at least 20 minutes of non-face-to-face care management services per patient each month. This includes time spent on phone calls, medication reviews, and coordinating with other providers. While 20 minutes may not sound like much, it adds up quickly across multiple patients. This is why many practices partner with a service that can provide a dedicated care team to handle this work, ensuring consistency for patients without overwhelming their in-office staff.
They are different, but they work together perfectly. Think of it this way: Chronic Care Management is the service of coordinating a patient's overall care through communication and planning. Remote Patient Monitoring (RPM) is a tool that helps you do that by collecting daily health data, like blood pressure or glucose levels. Combining them gives you both the data (from RPM) and the coordinated strategy (from CCM) to provide truly proactive care.
It's definitely possible, but it can be a heavy lift for a small team. The challenges often come from the administrative side—meticulously tracking time, staying on top of documentation, and ensuring compliance for every patient, every month. This is precisely why many small-to-midsize practices choose to work with a partner. A dedicated CCM service handles the staffing, technology, and compliance, allowing you to offer a high-quality program without the risk of burning out your team.