Managing patients towards better health outcomes.
We offer comprehensive chronic care management to patients with chronic conditions. Our solution is effective at managing Medicare eligible patients on behalf of physicians, hospitals, and payors in order to reduce hospitalizations, lower costs and improve outcomes.
How We Proceed
1. Identify eligible patients with chronic conditions
2. Obtain consent to enroll them in program
3. Create care plan & integrate EHR
4. Provide monthly care management services
5. Track time spent in contact with patients
6. Provide documentation for billing Medicare
How We Serve
Chronic Care Management
Monthly continuous support and coordination of medical services for patients with multiple chronic conditions
Principal Care Management
Monthly continuous support emphasizing prevention for patients with one chronic condition for improved health outcomes
Transitional Care Management
Facilitates the transition of patients from one healthcare setting to another, ensuring continuity and coordination of care to reduce hospital readmissions
Remote Patient Monitoring
Tracking patients' health data outside healthcare settings to manage and monitor their conditions remotely for better care
Value-Based Care Management Services
With MACRA, most clinicians will be measured against their peers in their ability to improve overall health outcomes and reduce claims for wasteful and unnecessary services, with contracted payments hinging on the results.
The Centers for Medicare and Medicaid Services in 2015 began to reimburse physicians for providing chronic care management services to Medicare patients who have chronic conditions under the Medicare Physician Fee Schedule (PFS).
Benefits of CCM
For Patients
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Improved self-management skills
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Improved quality of care and patient satisfaction
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Personalized coaching from a care manager
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Collaborative decision making and engagement
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24/7 emergency access to ChronicCare clinicians
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Creation of a customized, comprehensive care plan
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Access to personalized disease library
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Coordination of care between providers and other benefits
For Providers
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Compliance with MIPS/MACRA reporting requirements
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Earn new stream of recurring and reimbursable revenue
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Entry for value-based care and risk-based contracting
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Acquire and retain new patients
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Promotes patient loyalty and connection to practices
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Increased volume of patients, i.e., not losing patients
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No setup charges and no upfront and ongoing charges
