December 21, 2016

Increased Reimbursement for Care 

Coordination and the Potential Impact on 

Community Based Organizations (CBOs)

Welcome to TIM Talks:

Welcome to TIM Talks
Impact of Expanded Care 

Management on CBOs

Timothy P. McNeill, RN, MPH

Healthcare Consultant
Changes in Care Mgmt Payment

Key Takeaways for CBOs

Relevance to Health Reform

Next Steps 4

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2017 Physician Fee Schedule

• Proposed Ruling

– Posted November 15, 2016

– Regulation # CMS-1654F

– Available: https://www.gpo.gov/fdsys/pkg/FR-2016-11-

15/pdf/2016-26668.pdf

• Key Change related to CBOs

– Significant expansion in care management reimbursement

– Services can be outsourced to a third-party care 

management company 
Proposed Rules Applicable to CBOs

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• Chronic Care Management (CCM) 

• Complex Chronic Care Management

• Behavioral Health Integration (BHI)
Purpose of additional Care Management 

resources

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• Medicare Access and CHIP Reauthorization Act (MACRA)

– Physicians and other healthcare providers are mandated to shift 

towards a value-based payment model

– Reimbursement will begin to adjust based on outcomes for the 

population

– Physicians whose population of Medicare patients have better health 

outcomes and lower costs will receive higher reimbursement than 

physicians whose patient populations have worse outcomes and 

higher costs

– Physicians have an opportunity to expand care management to 

achieve improved health outcomes and receive compensation for 

providing the care management resources
Eligibility for chronic care management services

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• Medicare Part B beneficiary

– Medicare Only

– Dual Eligible 

• Two or more chronic conditions and risk of deterioration in 

health status if conditions are not managed well

• One of these chronic conditions can be a behavioral health 

condition

• Examples:

– Congestive Heart Failure with an comorbidity of depression

– Diabetes and heart disease
Concerns about access

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• MACRA mandates that CMS track access and utilization for 

chronic care management for high-risk groups including the 

following:

– Racial and ethnic minorities

– Rural Populations
Why would there be a limitations on Physician use?

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• These new services require the following:

– Establish a person-centered care plan for care management for each 

participant

– Have a clinical staff member that makes contact with each 

consumer each month and provide care management services 

according to the person-centered plan.

– Services must occur for at least 20 min with additional time 

reimbursable with newly acknowledge codes
Support for Physicians to Expand Utilization of CCM

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• Option to outsource services to a third party care 

management company with expertise in working with target 

populations

• Patient contact and care management is expected to be nonface-to-face

• Add-on code for reviewing the person-centered plan

• Services can be provided by “Clinical Staff” as compared to 

administrative staff

– Clinical staff can be leased employees, contractors, or employees of a third 

party care management company
CPT/HCPCS Codes and Rates 

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Code Description Time Req. Proposed Rates

99490 CCM 20 min $42.21

99487 Complex CCM 60 min $92.66

99489 Add-On CCM +30 min $46.87

G0507 Behavioral 

Health 

Integration

20 min $44.00

G0506 Person-Centered 

Planning Add-On

One-time 

reimbursement. 

Not associated

with time

$63.68
Description of the population receiving CCM today

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• 513,000 Unique Medicare beneficiaries received the service

• Frequency = 4 times per person

• Participants tend to have a higher disease burden and suffer 

from social determinants of health

• Recipients are more likely to be dual-eligible

• Physicians report clinical staff spending 45 – 60 min per 

month per beneficiary on CCM
Hospital Interview - December 2016

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• I conducted an Interview with a hospital with higher than 

average readmission rates and a higher volume of Medicaid 

Dual-Eligible beneficiary population

• TCM/CCM Solution: Outsourced care management to a forprofit third party care management company

• Findings: Third party company makes a person-centered 

plan and makes suggestions about community resources to 

obtain necessary services – “They often give patients the 

number to the Office of Aging to get help”

– Outcomes: Services not available (waiting lists)

– System difficult to navigate
Behavioral Health Integration (BHI)

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• Care Coordination for persons with a behavioral health 

diagnosis

• This service can be provided by a third party care 

management company

• Services can be reimbursed for the same beneficiary 

receiving CCM – during the same month

• BHI services

• Outreach and engagement

• Initial assessment/person-centered planning

• Development of patient registries

• Patient activation and health system navigation 
Economics of Expanded Care Management

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• Anywhere USA AAA

– 50 year experience providing care management services for older 

adults and persons with disabilities in our local market

– Medicaid Waiver provider with 60% of the waiver participants 

being dual-eligible beneficiaries

– Total Waiver population = 1,500 participants (900 Duals)

– Complex CCM for the 50% of the Duals in Waiver

– $450 X $92.66 = $41,697 per month

• Annual revenue = $500,364
Key Takeaways

• Primary population receiving CCM today includes dualeligible beneficiaries (total population = 513,000)

• MedPac data reports approximately 10 million dualeligible beneficiaries nationwide

• MACRA baseline performance established CY2017

• Physicians can outsource CCM to a third-party care 

management company

• Third party must provide services using U.S. based 

clinical staff (cannot outsource to foreign call center)
Key Takeaways Cont.

• Current participants are more likely to suffer from social 

determinants of health

• Health outcomes for dual-eligible populations are 

negatively impacted by social determinants

• Poor Health Outcomes = MACRA reduction in physician 

reimbursement (baseline established 2017)
The Potential Role of the CBO

• Operate as a third-party Care Coordination / Care 

Management provider

– Transitional Care Management (TCM)

– CCM / Complex Care Management

– Behavioral Health Integration (BHI)

• CBOs can become a direct supplier of services or support 

the provider to deliver these services

– Clinical integration between community-based organizations and 

providers impacted by Alternative Payment Models and 

MACRA

– Additional reimbursement pass through to CBO partner
Steps to Contracting for Care Management

• Market Analysis

• GAP Analysis

• Target physician groups serving the population that 

matches my strength and history

• Develop a business model that is cost-neutral to the 

provider

• Test the process for data capture and results starting with 

shared beneficiaries

• Transition model to reimbursement for care management 
Prepare for Potential Push-back

• Your Organization has no experience providing care 

management services

– We are the leading waiver case management provider in the 

region serving primarily duals and Medicaid and the only OAA 

service provider

• We cannot outsource the service unless your staff become 

our employees

– Regulations specifically allow physicians to outsource the 

service to a third party and have no employer relationship with 

the staff performing the work

– Services can be provided under General supervision
Prepare for Potential Push-back (cont.)

• You don’t have evidence-based programs for this population

– PEARLS, Stanford, Fall Prevention, etc.

• Only licensed staff can perform care management service

– Requirements include clinical staff using CPT definition (AMA 

specifically supporting Health Coaches for this purpose)

• ACA will be repealed and replaced

– MACRA is a separate bipartisan bill

• HIPAA prevents us from sharing any information with you 

to provide care management services

– Requirements specifically outline that HIPAA requirements DO NOT 

prevent a physician from sharing clinical information with third party for this purpose
Seize the Opportunity – “My AAA is the Premier 

Care Mgmt organization serving high-risk duals in 

our area”

• MACRA will impose penalties on physicians based on 

health outcomes

• CMS Data shows that dual-eligible status has a 

statistically significant impact on health outcomes

• Increased risk in the market will require a different 

approach to delivering care 

• Define the target population and/or geographic coverage 

area

• Have a clear contract model

– Who is the responsible party on the contract?

– Existing agency or network of CBOs

– One contract to cover region
Questions

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