Welcome to TIM Talks: 

Chronic Care Management (CCM) - Moving from 

Planning to Implementation

June 22, 2017
Timothy P. McNeill, RN, MPH
CCM Operations Process

Value-Added Benefits

Contract Models

Questions

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CCM in the Market place

• Customers for CCM Services:

– Health Systems that want to reduce readmissions 

– ACOs

– Health System-Owned Physician Practices

– Multi-Specialty Practices

– Physician Groups participating in bundled payment
Identify the Win-Win

• Provider

– Additional care management resources to support the patient 

population

– Extending disease self-management and lifestyle changing 

efforts beyond the clinic to the community

– Support to address MIPS, ACO Measures, and Cost containment

• CBO

– Profit center within my organization

– Direct referral source for evidence-based programs

– Best practice model that can be replicated to other 

customers in the market
Target Population: Payer

• Beneficiaries with Medicare Part B:

• Emphasis on Dual Eligible Beneficiaries

– Data shows significant increase in cost and disease burden 

associated with dual-eligible status

• Emphasis on persons with four or more chronic conditions

– Data shows significant increase in costs for any beneficiary 

with four or more chronic conditions

• Medicare Advantage Beneficiaries:

• Emphasis on persons receiving a low-income subsidy

– CMS study shows direct correlation between low-income 

subsidy status and performance on HEDIS measure 

outcome
Target Population: Disease Groups

• Diseases that are impacted by lifestyle choices

– Diabetes

– Heart Disease / Heart Failure

• Populations impacted by social determinants of health

– Low-Income 

– Minority

– Rural

• Populations that have a primary or secondary diagnosis of 

depression

– WHO: Depression is the leading cause of disability 

worldwide
Pilot the Process

• Identify One Provider within the organization to test the 

process

– Seek out a champion

– Develop a model of sharing clinical data

– Establish a process of targeting the participants

– CBO and Provider gain knowledge of the culture of the business

– Embed a health coach within the practice
Key Factors

• Business Associate Agreement 

• HIPAA Training of embedded personnel

• HIPAA Training for CBO staff supporting the project

• Health IT system

• Data exchange

• Bi-directional referral patterns

• Person-Centered Planning Process
Financial Considerations

• Total number of eligible patients

• Mutual expectations regarding referral volume

• Break-even point

• Charge capture process

• Revenue cycle management
Tracking Performance: Establish Mutual 

Expectations

• Financial

– Number of enrolled clients

– Services provided per beneficiary per month

– Billing generated per coach

– Aggregate billing per beneficiary per month

– Aggregate billing per population

– Administrative Fees

– Billing cycle

– Invoice timeline
Tracking Performance: Establish Mutual 

Expectations

• Clinical

– Primary diagnosis

• Depression status

• Malnutrition

– Readiness for change

– Need for social services

– Homebound status

– Dual-eligible status

– Medicaid Waiver enrollment / Managed LTSS

– OAA services

– Veteran Status

• VA Choice / VD-HCBS
Embedded Health Coach Qualifications

• Develop a personnel file for each Coach

– Job Description / Resume

– Background check

– Training

– HIPAA / Confidentiality statement

– TB testing / MMR / Flu

• Recommended Training

– HIPAA

– Motivational Interviewing

– Disease Self-Management skills

– Abuse, Neglect, Exploitation / Mandatory Reporting
Key Practice Personnel

• Embedded Health Coach and the Program Administrator 

must establish a relationship with the following key 

personnel:

– Practice Manager

– Front Desk Personnel

– Scheduler

– Practice Care Coordinator

– Billing Staff
Health Coach Routine - Prep

• Review the schedule for the week

– Appointment Reason

– Payer / Insurance Status

– Co-insurance (Medicaid, AARP / UHC, etc.)

• Daily assess the schedule for changes

• Coordinate with Practice Care Coordinator to target 

patients based on the schedule

• Report the daily list of potential clients to enroll
Health Coach Routine – Daily Operations

• Coordinate with front desk to greet clients prior to their 

provider appointment

• Introduce the program using defined script agreed upon 

by the practice administrator and the CBO

• Assess consumer willingness to participate

• Support the development of a person-centered plan

• Report the enrollment and person-centered plan to the 

provider

• Obtain endorsement from the provider for client 

engagement

• Document 

– Person-Centered Plan

Verbal Consent
Person-Centered Planning Key Elements

• Person-Centered Plan should span 12 Months

• Needs

– Medical

– Social

– Psycho-social

• Interventions

– Preventive Health appt. schedule

– Evidence-based programs 

– Individual Health Coaching

• Cultural Factors impacting health

• Social Determinants
Health Coach Routine – End of Day

• Record number of enrolled compared with potential 

eligible

• Compare enrollment to daily enrollment quota target

• Record financial and clinical quality measures

– Primary Diagnosis

– Depression Status

– Dual-Eligible Status

– Veteran Status

– Social Service Needs

– Zip Code or residence

– Enrollment in Medicaid Waiver / Managed LTSS
CBO Administrator Tasks - Administrative

• Daily assess status of meeting enrollment goals

• Identify barriers to enrollment and discuss them with the 

practice manager

• Assess the demographics of the population enrolled to 

determine if the program is reaching the target 

population

• Assess for monthly services provided to each beneficiary

• Monitor enrollment in programs provided by the CBO

– Evidence-based programs

– OAA Services

– Senior Center Programs

– Social Service Programs
CBO Administrator Tasks - Financial

• Monitor billing 

– Billing per beneficiary

– Aggregate billing for the program

– Billing compared to costs

– Reconciled billing

– Revenue-Cycle timeline

– Daily enrollments

– Productivity of embedded coach

– Cost of the embedded coach compared to enrollment 

numbers
12-Month CCM Service Plan

• In-Home Assessment to determine risk

– Assess for Fall Risks

– Review Medications and document findings

• OTC

• Use of Herbal Medication

• Adherence to Prescribed Medication Regimen

• Enrollment in scheduled Evidence-based programs

• Preventive Health appt. schedule

• Coordination with specialists
12-Month CCM Service Plan – Evidence-Based 

Programs

• Person-Centered Plan should support the person with 

completing all applicable evidence-based programs

• Health Coaching model supports the consumer with 

completion of planned participation in evidence-based 

programs

• Health coaching and individual participation in monthly 

evidence-based programs must be documented for each 

individual consumer – even if participant attends a group 

intervention
Sample Plan Using Evidence-based Interventions

• 68 y/o female. Widow and lives alone. Dual-Eligible. 

Dx Diabetes, CHF, Depression. Not receiving Medicaid 

wavier. Hx of recent fall

– Enhanced Wellness – Evidence-Based Health Coaching Program

– Fall Prevention Program (Matter of Balance, Stepping On, etc.)

– In-Home assessment for fall-risk and medication review

– CDSMP

– PEARLS – Depression management

– Enrollment in Medicaid Waiver for home-delivered meals and 

adult day-health

– Coordination of transportation to a DSMT / MNT class

• MNT / DSMT will be billed separately from CCM
CCM / Behavioral Health Integration

• CCM and Behavioral Health Integration services can be billed 

on the same consumer, during the same month

• Eligibility for Behavioral Health Integration

– Any Behavioral Health Condition

– WHO: Depression is the leading cause of disability worldwide

– Depression is a common co-morbidity of diabetes and heart disease

• Services must be documented separately for each intervention
Track Value-Added Benefits to the Practice

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• Adherence to Medical Office Visit Prevention Schedule

– Four Preventive Health Visits per year + sick visits ($$$)

– Annual Wellness Visit ($175 first year, $99 thereafter)

• Health Coach can support completion of Annual Wellness 

Visits

• CCM Support of Tele-Health Services

– Geographic Restrictions on Tele-Health are lifted for the 

following beneficiaries:

• Participants in a bundled payment program, during the episode 

of care

• Consumers in a Next Generation ACO
Is there a Bundled Payment Program Near You?
CONTRACT MODELS

CCM Implementation:
Contract Models

• Model #1: Clinical Integration with one individual 

Medicare Provider

• Model #2: Contract with a organization that can bill 

Medicare and support multiple providers in a market

• Model #3: Become a direct Medicare provider with the 

appropriate infrastructure to deliver CCM services
MODEL #1: 

CLINICAL INTEGRATION 

WITH ONE INDIVIDUAL 

MEDICARE PROVIDER
Contract Model

• Individual Contract with an individual provider / group 

practice to provide CCM services as a third-party care 

management organization

• Contract defines the services, cost of services, and 

expected payment schedule

– Admin costs should be limited to 10% or less

• CBO provides the services and documents in the E.H.R of 

the provider

• Provider submits claims to insurance

• Provider and CBO reconcile with the collections 

department on a regular schedule.
Pros vs Cons

• Pros

– Ability to quickly start

– Ready source of consumers

– Sets precedence and marketing material for other practices

• Cons

– Agreement is limited to one individual provider and will require 

separate agreements with every other individual provider

– Embedded Health Coaches and staff will have to learn and adopt 

the E.H.R for each contracted provider

– Increased administrative costs to manage and track services with 

multiple systems and multiple providers
Financial Considerations

• Agreement limited to one practice and the billing is 

limited to that provider’s capacity 

• Track claims submission, denials, aging report

• Increased administrative costs to the CBO if this contract 

model is replicated to multiple practices in the market

• Training costs associated with staff use of multiple IT 

systems 
MODEL #2: 

CONTRACT WITH A 

ORGANIZATION THAT CAN 

BILL MEDICARE AND 

SUPPORT MULTIPLE 

PROVIDERS IN A MARKET
Contract Model

• Contract with an established Medicare Provider or 

Management Service Organization (MSO) that has the 

capacity to work with multiple providers in the market

• MSO should provide

– E.H.R platform that integrates with multiple providers

– Revenue Cycle Management

– Reporting / Population Health Mgmt.

• MSO will take an administrative fee

– Range is 20% - 45%

– MSO accepts the risk, liability, and IT costs
Pros vs Cons

• Pros

– Ability to integrate with multiple providers in the market using 

one IT system platform

– Risk and liability are borne by the MSO

– Lower administrative costs related to the use of one IT platform, 

one tracking system, one claims management process, and one 

reporting venue

• Cons

– Increased costs associated with the MSO fee

– MSO must be flexible and agreeable to modify IT platform 

to meet the needs of the provider and CBO
Financial Considerations

• MSO entity provides at least one qualifying visit with the 

beneficiary

– Annual Wellness Visit

– TCM

– In-home primary care / Preventive Health visit

• MSO enrolls the consumer

• CBO supports the completion of the person-centered plan

• CBO implements the person-centered plan

• CBO and MSO work collaboratively to increase client 

compliance with primary and specialty care appts. 

and preventive health appt. schedule
MODEL #3: 

BECOME A DIRECT 

MEDICARE PROVIDER WITH 

THE APPROPRIATE 

INFRASTRUCTURE TO 

DELIVER CCM SERVICES
Contract Model

• CBO becomes the provider

• CBO bears 100% of the risk and costs of the program

• CBO keeps 100% of collections

• CBO must establish a process to complete a qualifying 

visit for each consumer and have the appropriate 

personnel that are eligible to deliver the qualifying visit
Pros Vs Cons

• Pros

– CBO keeps 100% of collections

– CBO does not have to negotiate with third parties for program 

– CBO can immediately target current client base for services

• Cons

– CBO bears 100% of the risk and liability

– CBO must establish a process for revenue-cycle management

– CBO must bear 100% of the costs of the Health IT system and 

system integration costs

– Higher upfront costs and risk to the CBO

– Lack of economies of scale
Financial Considerations

• Malpractice liability

• Cyber Insurance

• Health IT system costs

• Revenue-cycle management costs

• HIPAA compliance

• Referral sources 

• IT integration with providers in the marketplace