Chronic Care Management (CCM) is a program designed by Medicare to provide continuous care coordination for patients with multiple chronic conditions. Brilliant Care offers a turnkey CCM solution for clinics and health systems, acting as your partner to deliver these services efficiently and effectively. Our CCM services fulfill all Medicare requirements for non-face-to-face care coordination, while improving patient outcomes and generating additional revenue for your practice.
What is CCM? Medicare’s Chronic Care Management program (CPT 99490 and related codes) allows clinicians to provide care coordination for patients with 2 or more chronic conditions. This includes tasks like monthly check-in calls, medication management, referral coordination, and creation of comprehensive care plans. We handle these tasks on your behalf with our dedicated team of nurses and coordinators, ensuring each eligible patient receives personal attention every month.
We help identify Medicare patients in your panel who qualify for CCM. Typically, these are patients with diagnoses like diabetes, hypertension, arthritis, depression, CHF – any combination of two or more chronic issues expected to last 12+ months. We obtain patient consent to enroll in the program (a Medicare requirement) and educate them on how it works.
Each patient is assigned a dedicated care coordinator (usually a nurse or specially trained health coach). That coordinator contacts the patient at least once a month (often more for high-risk individuals). During these calls, we assess the patient’s health status, remind them of upcoming appointments, review medications, answer any questions, and help them navigate any issues. These conversations are documented thoroughly.
We establish a personalized, electronic care plan for each CCM patient, accessible to the provider. This includes the patient’s health goals, symptom monitoring, medication list, and any community or social services they might need. The care plan is updated as conditions change. Patients feel supported knowing there’s a plan and someone checking in regularly on their progress.
If the patient has seen a specialist, or needs help setting up an appointment (e.g., an eye exam for a diabetic patient), our team takes care of it. We ensure all providers involved in the patient’s care are on the same page. We can also assist with arranging services like nutrition counseling, managing home health orders, or connecting patients to resources for financial or transportation assistance.
As part of CCM, patients have 24/7 access to a member of clinical staff. Outside of scheduled monthly calls, they have to be able to reach out to clinical staff with concerns. For instance, if a patient with COPD in the program experiences breathing issues after-hours, they can call the 24/7 line – potentially preventing an ER visit through timely intervention.
We provide regular summaries to the primary care provider. After each significant patient interaction, we document updates. If there’s a concerning development (e.g., patient reports worsening depression or can’t afford a medication), we alert the physician immediately. Once a month, we update the patient’s chart in the EHR. This way, you stay informed and in control of your patient’s care plan, without having to make all the calls yourself.
ECCM has demonstrated multiple benefits. Patients in CCM tend to have fewer hospitalizations and emergency visits, as ongoing support helps manage issues before they escalate. An analysis by CMS found that a well-run CCM program reduced overall costs by ~ $74 per patient per month over 18 months, thanks to lower hospital, ER, and nursing home utilization. Another study linked CCM participation with a reduced likelihood of hospital admission in conditions like diabetes, COPD, and heart failure. This shows CCM not only pays for itself but actually saves money for the healthcare system while keeping patients healthier. Patients also report high satisfaction with CCM – they value the “extra” support and guidance in between doctor’s visits. Knowing they can call a care team anytime gives them peace of mind and helps them stick to their care plan.
From a practice perspective, CCM services are reimbursed by Medicare roughly ~$65 (national average) per patient per month for the base service (with higher payments for complex CCM or additional time). We handle delivering the services, assist with billing and coding for CCM encounters, ensuring all documentation meets requirements. For example, our platform logs the time spent on care coordination each month to substantiate the billing. We often provide this service without any out-of-pocket cost to the practice by sharing in risk or operating on value-based contracts – so it’s essentially a win-win financial proposition.
Brilliant Care’s CCM program is turnkey. We provide the technology (our care management software integrates with your EHR to document everything), the people (experienced nurse coordinators who operate as an extension of your practice), and the process (established protocols that align with Medicare rules and clinical best practices). You maintain control over patient care without the workload – we’re constantly in touch with your team for any issues, so you don’t need to hire full-time staff to realize the benefits of CCM.
In short, we improve access to care, which increases patient satisfaction and loyalty, and we leverage technology to make care more efficient. For organizations pursuing value-based care, CCM is often a cornerstone program – and we make it easy to implement and scale.
If you want to offer your chronic patients personalized, between-visit support that keeps them healthier (and recognizes you financially for that effort), Brilliant Care’s Chronic Care Management service is the answer. We’ll help your patients feel “surrounded” by care, while you see the benefits in both outcomes and practice performance.