Medicare has offered reimbursements to physicians for Chronic Care Management services since 2015. But still, providers are struggling with patient engagement, education, efficient processes and regulatory compliance.

CCM provider provides 20 minutes of monthly non-face-to-face care management services for beneficiaries with two or more chronic conditions. It helps in managing their conditions, risk factors, medication adherence, and coordination of care with other providers. To bill for CCM services, practices must offer

• 24/7 access to care management services
• a platform for direct patient-practitioner communication
• ability to manage transitions between providers and settings

Why are hospitals outsourcing CCM services?

CCM program is a labor-intensive process. It requires

• Recruitment and training certified staff
• EHR systems to track care plans
• Monitor and document monthly calls
• Making staff available to patients 24/7
• More office space

In order to avoid these challenges, hospitals are outsourcing CCM services.

Advantages of outsourcing CCM services

1. New significant revenue stream – A small hospital cannot afford costly EHRs, handle staff-patient management, etc. These aspects are important for chronic care management implementation. Hence they are outsourcing CCM services. The outsourcing agencies specialize in CCM services and take a part of the profit from the practice. It generates a new significant revenue stream for practices who otherwise cannot get Medicare CCM reimbursements.
2. Saves physician’s time and effort – Outsourcing CCM services overcome the time-intensive CCM challenge for many physicians. Many of them do not have the professional staff bandwidth to provide the continuous chronic care management services. The new CMS initiative of paying doctors for CCM services works well with outsourcing.
3. Better patient satisfaction– The billing physician creates a specific healthcare plan for his patients. The physician then turns that plan over to the CCM vendor who is responsible for the daily or weekly contact with the patient. The CCM vendor monitors the patient’s progress and provides health coaching according to the physician’s care plan. The vendors must make sure that the patient is adhering to the plan and keep the physician posted. This allows the physician to extend his chronic care management to more patients with the required staff bandwidth.
4. Improved patient interaction – Outsourced services can combine technology, clinical services, and analytics with minimal efforts from the physician’s end. It results in improved patient interactions between actual office visits, with no impact on their current professional staff.
5. Increased patient enrollment – Outsourcing CCM will allow the physician to

• increase and maximize patient enrollment in the program
• improve patient compliance
• provide CCM documentation requirements

    while minimizing the physician’s workload.

Risks of outsourcing CCM services

1. Risk Management – Outsourcing CCM may sound easy on the front end, but it is very hard to mitigate the risks on the back end. Medicare fraud violations cost up to $10,000 per incident and may even subject the physician to a jail term. Outsourced CCM services make the practice actively and directly responsible for multiple risk factors:

• Is the person performing the work appropriately credentialed to work in the state (especially nursing-staffed call centers)? Has the practice taken active steps to confirm this is?
• Are all of the services billed for on the claims actually performed? Is the practice actively performing spot checks to ensure same?
• Is the practice periodically checking that the documentation they receive for these claims and services is actually legitimate?
• Is patient’ privacy taken care of? It is HIPAA-compliant?
• Is the practice provided audit logs to protect them if they are audited? How often do they receive audit logs?

Never forget that an outsourced CCM vendor is paid on the volume while you hold 100% of the risk. At a minimum, this creates misaligned incentives and requires the practice’s perpetual and diligent oversight.

2. Profit factor – CCM vendors may take from half up to two-thirds of the CCM reimbursement for complete outsourced CCM service. When the added expenses are taken out of the payment, a practice may get only $7 to $12 per patient. In addition to paying the third party, it also has the labor cost of

• Filing the claim
• Paying the clearinghouse and the biller
• Collecting $8 copay.
• At one point, there is no profit from outsourced services

3. Patient’s experience – When a practice outsources the CCM services, the CCM vendor takes care of following up with the patients. Every time a patient gets a call, the person calling for rendering CCM service is unknown to them. The patients are not happy with different people calling them up every month. The vendors will not be fully aware of the patient’s medical history resulting in an average CCM call. The patient will also not feel good about talking to random people every month. Patients become dissatisfied with the outsources CCM services and leave the network.

4. Losing continuity with patients – In outsourced CCM, the practice does not get in touch with their patients regularly. When the patient visits the hospital, the physician will have to go through the previous CCM service history. It is better for the practice to do CCM services rather than give it to a CCM vendor. It affects the practice’s patient network and results in revenue loss.

Outsourced CCM services have a  mix of advantages and risks. HealthViewX Chronic Care Management solution supports outsourced CCM as well as CCM services provided directly by the practice. The risk factor associated with outsourcing CCM is minimal in HealthViewX Chronic Care Management software.

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler,

• Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
• Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
• Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
• Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
• Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the reimbursements.
• HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution has features that suit practices as well as CCM vendors. To know more about our Chronic Care Management solution, schedule a demo with us.

References

http://www.federalcharges.com/medicare-fraud-charges-penalties/