Managing patients with chronic conditions takes time, coordination, and compassion—often far beyond what happens inside the exam room. Your team spends hours each month reviewing charts, coordinating with specialists, and helping patients manage medications, yet most of that work goes unbilled. Chronic Care Management (CCM) was designed to change that. Recognized by Medicare and many commercial payers, it’s a structured, reimbursable program that compensates providers for the non-face-to-face care their teams already deliver. In this blog, we’ll explain what CCM is, how it works operationally, which patients qualify, and how your practice can use it to improve outcomes, reduce staff burden, and generate reliable new revenue.
Key takeaways
- Extend care beyond the clinic walls: CCM is a formal, reimbursable program that allows you to provide continuous, proactive support to patients with two or more chronic conditions, improving their health between office visits.
- Improve patient health and practice revenue: By implementing a CCM program, you can reduce hospitalizations and help patients feel more in control of their health, all while creating a new, reliable revenue stream for your practice.
- Getting started doesn't have to be complicated: With a straightforward patient consent process and clear billing codes, you can launch a CCM program efficiently, especially when partnering with a service that handles the administrative lift.
What is Chronic Care Management (CCM)?
Think of Chronic Care Management (CCM) as a structured framework that enables your practice to extend care beyond the walls of the clinic. It’s a specific program, recognized and reimbursed by Medicare, designed to provide continuous care for patients with two or more chronic conditions. Instead of only seeing patients during scheduled appointments, CCM allows you to offer ongoing support through phone calls, secure messaging, and care coordination. This proactive approach helps patients manage their health better, stay on track with their treatment plans, and feel more connected to your practice.
For your practice, implementing a CCM program means you can provide a higher level of care that leads to better patient outcomes and fewer hospitalizations. It also creates a new, consistent revenue stream for the non-face-to-face work your team is likely already doing. By formalizing this care, you can get reimbursed for the time spent coordinating with specialists, managing medications, and educating patients between visits. It’s about delivering comprehensive, preventative care that truly makes a difference in the lives of those managing long-term health issues.
What a CCM program includes
A robust CCM program is much more than just a monthly check-in call. It’s a comprehensive service designed to wrap a layer of support around your patients. This typically includes personalized assistance from a dedicated care manager who acts as a consistent point of contact. A key component is providing patients with 24/7 access to a healthcare professional for urgent needs, preventing unnecessary emergency room visits. The program also focuses heavily on the coordination of care between your practice, specialists, pharmacies, testing centers, and hospitals, ensuring everyone is on the same page and nothing falls through the cracks.
Every interaction, from time tracking to care plan updates, should be automatically documented and audit-ready. Building compliance into each workflow ensures that your CCM program stays protected during payer reviews and supports reliable, timely reimbursement.
How CCM works day-to-day
Daily, CCM involves consistent, non-face-to-face engagement with your patients. This includes regular communication through phone calls or secure digital messages to review their medical records, check on their symptoms, and provide education on how to manage their conditions effectively. Your care team will also coordinate with other providers and community services to ensure all aspects of the patient's health are addressed. A crucial requirement is that patients must have 24/7 access to a clinician for urgent needs. This structure allows you to proactively manage your patients' health, address issues before they escalate, and provide peace of mind.
Common conditions covered by CCM
To qualify for CCM, a patient must have at least two chronic conditions that are expected to last for a minimum of 12 months. These conditions should place the patient at significant risk of functional decline or even death. While the list of qualifying conditions is extensive, some of the most common ones you’ll see in your practice include hypertension, diabetes, heart disease, arthritis, and chronic obstructive pulmonary disease (COPD). Other qualifying conditions can include cancer, depression, and substance use disorders. This breadth allows you to offer CCM services to a large portion of your patient population who need extra support.
Who qualifies for a CCM program?
CCM isn't just for anyone; specific criteria from Medicare ensure the program reaches the patients who need it most. Understanding these qualifications is the first step to successfully implementing CCM in your practice. It’s a straightforward process that involves meeting specific patient health requirements, following provider guidelines, and getting patient consent.
When you partner with a turnkey service like 1bios, you can be assured that every box is checked, so you can focus on patient care while we handle the administrative details. Let’s walk through exactly what’s needed from your patients, your practice, and the enrollment process itself.
Medicare eligibility for patients
As stated above, patients must have two or more chronic conditions to be eligible for a CCM program. These aren't temporary illnesses; they are long-term health issues like diabetes, hypertension, or heart failure that are expected to last for at least a year.
Crucially, these conditions must place the patient at significant risk of functional decline or even death. The goal of CCM is to provide proactive, continuous care to manage these conditions and prevent them from worsening. This focus on high-risk patients is what makes the program so effective at improving health outcomes and reducing hospitalizations. It’s about providing consistent support between office visits for those who genuinely need it.
Requirements for healthcare providers
While your clinical staff can perform many day-to-day CCM tasks, the services must be billed by a qualified provider, such as a physician, nurse practitioner, or physician assistant. This structure allows you to delegate the workload effectively.
You should anticipate that your CCM program comes with an additional administrative load. Many practices choose to work with turnkey CCM partners that handle enrollment, documentation, and billing behind the scenes, ensuring compliance and freeing in-clinic teams to focus on direct patient care. Using a partner like 1bios can offload these tasks from your in-house team, freeing them up for in-person appointments while our trained care team delivers the remote services.
The simple consent process
Before you can begin providing CCM services, you must get your patient’s consent. This is a critical step for both compliance and patient engagement. The good news is that the process is simple—consent can be given verbally or in writing and must be documented in the patient’s health record.
During this conversation, you’ll explain what CCM is, how it will benefit them, and that they have the right to stop services at any time. After getting consent, you’ll create a comprehensive, personalized care plan. This plan acts as a roadmap for their care, and you must provide a copy to the patient. This transparency helps build trust and empowers patients to take an active role in managing their health.
How CCM supports continuous, coordinated care
A CCM program is more than a series of monthly check-ins—it’s an operational framework for delivering consistent, high-touch support between office visits. Effective CCM programs provide patients with a dedicated care manager who serves as their ongoing point of contact and ensures care plans stay on track. A strong program also guarantees patients have 24/7 access to a qualified clinician for urgent needs, reducing unnecessary emergency department visits and improving continuity of care.
Behind the scenes, the program enables your team (or your CCM partner) to coordinate across specialists, pharmacies, and hospitals so that every provider involved in a patient’s care is aligned. This coordination not only enhances the patient experience but also ensures your documentation, billing, and compliance workflows are consistent and audit-ready.
How care is coordinated
Managing chronic conditions often means juggling multiple specialists, tests, and prescriptions. A well-structured CCM program brings all of these moving parts together. Each enrolled patient is assigned a dedicated care manager who oversees communication, ensures test results are shared, and reconciles medication lists across providers. This organized approach reduces duplication, prevents conflicting treatments, and helps your practice deliver a more cohesive care experience—without adding administrative strain to your in-office team.
Help with medication management
Medication oversight is a central function of CCM. Regular medication reviews help ensure patients are taking the right prescriptions, at the right time, and in the right combinations. Your care team—or your partner’s remote care staff—can proactively identify potential interactions, adjust regimens in collaboration with prescribers, and manage refills. These activities improve patient safety and adherence while generating reimbursable CCM time that supports your practice financially.
Educational health resources & patient management
Education is another key driver of CCM success. Rather than generic materials, the most effective programs deliver targeted, condition-specific guidance—such as dietary tips for diabetic patients or self-monitoring best practices for hypertension. These educational touchpoints keep patients engaged and informed, improving adherence and long-term outcomes. For your practice, this translates into stronger relationships, better quality metrics, and greater program retention.
Communication and availability
CCM provides patients with continuous access to care between office visits, often through phone calls, secure messaging, or telehealth. Many practices rely on U.S.-based care coordinators who act as extensions of their clinical team, ensuring timely, personalized responses to patient concerns. This consistent communication prevents gaps in care while allowing your in-office staff to focus on higher-acuity visits.
Technology and tools
Modern CCM programs use technology to improve efficiency and compliance. Most practices use EHR-integrated patient portals or mobile platforms for secure messaging and documentation. More advanced programs now include AI-powered tools that flag potential health risks, streamline note-taking, and surface actionable insights for clinicians. Some practices also pair CCM with Remote Patient Monitoring (RPM) devices—such as connected blood pressure cuffs or glucose meters—to give care teams real-time visibility into patient health and allow for more proactive intervention.
The real-world benefits of CCM
Implementing a CCM program is about more than checking regulatory boxes; it’s about delivering measurable improvements in both patient outcomes and practice performance. CCM turns the non-face-to-face work your team already does into a structured system of proactive engagement. The result is better care continuity, stronger patient relationships, and new recurring revenue that supports long-term sustainability. Below are some of the most tangible benefits practices experience when CCM is done right.
Achieve better health outcomes
At its core, CCM helps practices manage chronic conditions before they escalate. Regular communication, medication reviews, and care plan updates ensure that small issues are addressed early, preventing costly complications and hospitalizations. This proactive model leads to more stable health metrics across your patient panel and supports stronger performance on quality measures like readmission rates and A1C control.
Enhance patient satisfaction and retention
CCM builds consistent relationships between your team and patients—often with dedicated care managers who become trusted points of contact. This consistent engagement helps patients feel supported between visits, which directly impacts satisfaction and loyalty. Practices offering CCM often see higher retention rates and more positive feedback, as patients experience more accessible, coordinated care.
Improve medication adherence and safety
Medication management under CCM provides a structured way to keep complex regimens on track. Regular reviews help identify duplications, side effects, or adherence barriers, while refill coordination reduces the risk of lapses in treatment. This not only improves patient safety but also drives better clinical outcomes, all while adding billable activity to your monthly CCM time.
Reduce hospitalizations and avoidable costs
CCM’s proactive monitoring and communication significantly reduce avoidable hospital admissions and ER visits. When patients have consistent access to a care coordinator and receive timely follow-ups, small problems rarely escalate into emergencies. For practices, this means fewer reactive episodes, improved quality reporting, and stronger payer relationships—all while lowering total cost of care for patients and insurers alike.
Create predictable, sustainable revenue
While CCM is first and foremost a quality-of-care initiative, it also creates financial stability. Each patient enrolled in a compliant program generates recurring monthly reimbursement for work your team already performs—care coordination, medication management, and documentation. Over time, these payments create a steady revenue stream that supports staffing, technology investments, and continued patient engagement. When paired with strong compliance and documentation systems, CCM can be one of the most reliable contributors to your practice’s long-term financial health.
CCM is a well-established, reimbursable service recognized by Medicare and most major commercial payers. These programs were created to support proactive, continuous care for patients with multiple chronic conditions—and to compensate practices for the essential, non-face-to-face work that makes that care possible.
How CCM is covered and reimbursed
One of the first questions practices ask about CCM is how reimbursement works. The good news: CCM is a well-established, reimbursable service recognized by Medicare and most major commercial payers. These programs were created to support proactive, continuous care for patients with multiple chronic conditions—and to compensate practices for the essential, non-face-to-face work that makes that care possible.
Understanding the specifics of coverage is key to building a financially sustainable CCM program. Clear knowledge of payer requirements allows your team to explain the program confidently to patients, set accurate expectations about any potential costs, and maintain compliant billing workflows. While details vary by payer, the principle is consistent: insurers reimburse practices for the ongoing care coordination that helps keep patients healthier and out of the hospital.
Medicare reimbursement
Medicare was the first payer to formalize reimbursement for CCM and continues to set the standard for other insurers. To qualify for coverage, patients must have two or more chronic conditions expected to last at least 12 months—or until the patient’s death—and those conditions must place them at significant risk of functional decline.
Under Medicare’s guidelines, practices can bill for the non-face-to-face time spent managing these patients each month, including care plan development, coordination with specialists, and medication management. Reimbursement levels vary depending on the total time documented and the complexity of the case, but the structure provides predictable recurring revenue tied directly to the work your team already performs.
By reimbursing this work, Medicare supports a more modern, continuous model of care—one that rewards prevention, communication, and better long-term outcomes rather than reactive, episodic treatment.
Private payer coverage
Many commercial insurers have adopted similar reimbursement models for CCM, though requirements can vary by plan. Some payers align closely with Medicare’s CPT codes, while others may have different documentation or time thresholds. For that reason, it’s critical to verify eligibility and coverage before enrolling each patient.
Most practices streamline this step by using automated eligibility checks or working with a turnkey CCM partner who manages payer verification and ongoing billing compliance. This ensures no eligible patients are missed and that claims are submitted accurately the first time—reducing denials and improving cash flow consistency.
Patient responsibility and communication
Even though the primary audience is the practice, patient transparency still matters. For Medicare beneficiaries, the out-of-pocket structure is straightforward: after meeting their annual Part B deductible, patients are typically responsible for a 20% coinsurance on the Medicare-approved amount for CCM services. Many have supplemental insurance that covers this entirely, leaving little or no out-of-pocket expense.
Clear, upfront communication about coverage and potential costs not only builds trust but also increases enrollment rates. Patients are far more likely to consent when they understand both the value and affordability of the service.
Billing and documentation best practices
Because most CCM activities occur outside of in-person visits, meticulous documentation is essential for compliant billing. Every minute spent on eligible CCM services must be recorded in the patient’s certified electronic health record (EHR), including phone calls, care plan updates, and coordination activities.
A well-structured CCM system should automatically log time, communications, and care plan updates in an audit-ready format, ensuring your program stays compliant and protected during payer reviews. This level of documentation not only safeguards reimbursement but also strengthens your practice’s ability to demonstrate value to payers and patients alike.
Ultimately, CCM reimbursement success comes down to three pillars: accurate documentation, consistent workflows, and compliance-first processes—the same principles that distinguish high-performing, scalable CCM programs.
How to get started with CCM
Launching a CCM program doesn’t have to be complicated. For most small and mid-sized practices, success starts with setting up the right workflows, ensuring compliance, and having a plan for enrollment, documentation, and billing. Whether you manage CCM in-house or through a turnkey partner, the goal is to build a scalable, compliant process that integrates seamlessly with your existing clinical operations.
The enrollment process, step-by-step
Every effective CCM program begins with identifying eligible patients. Using diagnosis codes and problem lists in your EHR, your team (or your CCM partner) can generate a list of patients with two or more chronic conditions expected to last at least a year. From there:
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Confirm eligibility and payer coverage: Verify each patient’s payer criteria and benefits to ensure reimbursement before outreach begins.
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Obtain consent: Consent (verbal or written) is required before services can begin. Document this in the EHR along with the patient’s understanding of potential cost-sharing.
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Develop and share the care plan: Create a comprehensive, patient-specific care plan that outlines goals, interventions, and coordination needs. Provide a copy to the patient to meet compliance requirements.
Automating these early steps or delegating them to a trusted partner can dramatically reduce administrative workload and accelerate program launch.
Partnering with a care management team
Once your program is live, ongoing care coordination becomes the engine that drives both patient outcomes and reimbursement. Many practices choose to collaborate with U.S.-based care coordination teams that act as extensions of their staff—handling monthly check-ins, documenting encounters, and coordinating with specialists. This model allows providers to deliver continuous, high-quality care without stretching their internal resources thin.
Working with an experienced, onshore team also ensures cultural alignment, stronger patient relationships, and strict adherence to HIPAA and payer compliance requirements.
Technology and tools to support your program
Technology is critical for running a compliant, efficient CCM program. EHR-integrated tools or purpose-built CCM platforms can automate time tracking, generate audit-ready reports, and simplify communication across care teams. Platforms that embed AI into these workflows can automatically flag at-risk patients, streamline documentation, and surface the most relevant insights for clinicians—freeing staff from manual tracking and accelerating decision-making. Some programs also combine CCM with RPM, enabling clinicians to track vitals such as blood pressure or glucose remotely. This combination enhances visibility into patient trends, supports timely interventions, and increases billable opportunities.
More advanced platforms now use AI-powered tools to identify at-risk patients, flag care gaps, and streamline documentation—reducing manual effort while maintaining full compliance.
Patient education and engagement
While CCM is designed to lighten your team’s workload, patient engagement is still a key success factor. Providing clear, condition-specific education materials and regular outreach helps patients understand the value of the program and remain active participants. Turnkey partners often handle this engagement through scripted calls, texts, or secure messaging, ensuring every patient feels supported without adding to your staff’s responsibilities.
Getting started with CCM is less about adding new work—and more about formalizing the care your team already provides. With defined workflows, clear documentation standards, and the right technology or partner in place, your practice can quickly turn chronic care coordination into a sustainable, compliant source of recurring revenue.
Getting the most out of your CCM program
Launching a CCM program is only the first step. The real success comes from how well your practice integrates CCM into daily workflows, keeps patients engaged, and ensures consistent documentation and billing. When managed effectively, CCM becomes a cornerstone of your care model—improving outcomes, increasing satisfaction, and generating sustainable recurring revenue. Here are a few proven ways to maximize the value and performance of your CCM program.
1. Build consistent workflows
Consistency is key to running a successful CCM program. Establish clear processes for enrollment, consent, monthly touchpoints, and documentation. Regular scheduling and standardized scripts for care team calls ensure patients receive timely outreach and consistent support. Practices that maintain structured, repeatable workflows typically see higher engagement, better adherence to care plans, and more reliable reimbursement.
2. Use your technology effectively
Your CCM platform or EHR integration is the foundation of your program’s success. Ensure your staff is trained to use every available feature—from automated time tracking to patient dashboards and reporting tools. If you’re using Remote Patient Monitoring (RPM) alongside CCM, set up alerts and data review protocols so your care team can act quickly on trends. Leveraging technology effectively allows you to scale your program, maintain compliance, and minimize manual effort.
3. Communicate clearly within your care team
Internal communication is just as important as patient communication. Make sure your CCM team, providers, and billing staff share visibility into each patient’s status, care plan updates, and documented time. Use standardized communication templates or shared EHR notes to reduce redundancy and ensure every encounter is logged. Practices that prioritize internal coordination are better equipped to stay audit-ready and maintain a seamless patient experience.
4. Track performance and outcomes
Successful CCM programs are data-driven. Monitor metrics such as patient enrollment rates, monthly billing volume, engagement frequency, and hospitalization reductions. Regularly review reports to identify which patients need re-engagement and where workflows can be improved. Tracking and acting on this data allows you to demonstrate value to payers and continually optimize both clinical outcomes and financial results.
5. Refine patient engagement strategies
Even with strong internal systems, patient engagement drives long-term retention and reimbursement. Use a consistent outreach cadence—monthly calls, texts, or secure messages—to keep patients involved. Providing targeted education and clear next steps after each interaction reinforces trust and helps patients stay invested in their care. Many practices find success partnering with CCM service providers that manage these interactions professionally while maintaining compliance and consistency.
Summary
CCM is more than a billing mechanism—it’s a proven framework for proactive, continuous care. When implemented and maintained effectively, it strengthens patient relationships, improves outcomes, and transforms the non-face-to-face work your team already performs into a reliable, compliant revenue stream. With well-defined workflows, the right technology, and consistent patient engagement, your practice can deliver higher-quality care while reducing the administrative burden on your in-house staff.
Related articles
- Turnkey Chronic Care Management (CCM)
- 2025 Payment Rates for RPM, CCM, and other Virtual Care Programs
- CCM Solution ROI Revenue Calculator
- Chronic Care Management: The Definitive Guide
- Chronic Care Management CPT Codes: A Comprehensive Guide for Providers
- Medicare and Chronic Care Management: How It Works & Why It Matters
- How to Start a Chronic Care Management Program
- Top 7 Chronic Care Management Software Solutions
Frequently asked questions
My staff is already stretched thin. How much extra work is a CCM program?
This is the most common concern we hear, and it's a valid one. While a CCM program does require consistent time for patient check-ins, care planning, and documentation, you don't have to do it all yourself. The entire point of partnering with a service like 1bios is to offload that work. We handle the monthly calls, the coordination with specialists, and the detailed documentation, which frees up your in-house team to focus on the patients right in front of them.
How is CCM different from Remote Patient Monitoring?
It's helpful to think of them as two sides of the same coin. Chronic Care Management is the service of ongoing communication and care coordination—the monthly calls, medication reviews, and goal setting. Remote Patient Monitoring is a technology that collects daily health data, like blood pressure or glucose levels. They work beautifully together, with RPM data giving your care team valuable insights to discuss during CCM calls, but they are distinct services.
How do I explain the potential co-pay to patients without scaring them away?
Transparency is key. It's best to frame it as a small investment in their health. Explain that for a minor monthly co-pay, they get a dedicated care professional who is available to them between appointments. You can also mention that many supplemental insurance plans cover this cost completely. Most importantly, contrast this small, predictable cost with the potentially huge expenses of an emergency room visit or hospital stay that proactive care helps prevent.
Can we really bill for phone calls and other work done outside of an office visit?
Yes, absolutely. That’s the fundamental value of the CCM program. Medicare and other insurers created these specific billing codes because they recognize that the care happening between appointments is critical for managing chronic disease. The key to getting reimbursed properly is meticulous time-tracking and documentation for all qualifying activities. This ensures you have a clear, auditable record of the services you provided.
What if a patient is already seeing multiple specialists?
That’s actually an ideal scenario for a CCM program. A patient juggling a primary care doctor, a cardiologist, and an endocrinologist is precisely who benefits most from care coordination. The CCM program doesn't replace those specialists. Instead, it acts as the central hub, ensuring everyone is on the same page, medication lists are reconciled, and test results don't fall through the cracks. This reduces the burden on the patient and helps prevent conflicting treatments.
