By Deepika Kumar
Our patient segmentation model finds that for MSSP populations across the country, most patients fall into the major complex chronic illness segment (to qualify for this segment, a patient must have two or more complex conditions or at least 6 non-complex conditions) and historically most of the day-to-day work providers were doing to manage patients with multiple chronic conditions went uncompensated. However, we then fast forward to 2015 when CMS introduced the Chronic Care Management codes to provide reimbursement for non-face-to-face care coordination services to eligible Medicare patients with two or more chronic conditions – which theoretically sounds like great news for providers.
The trouble is — anecdotally, we hear from our members that pitching CCM to providers has not been well-received. Establishing a CCM program is a labor-intensive process, typically requiring the recruiting and training of certified staff who will need ongoing training, technology and EHR systems to track care plans and document monthly calls. Quantitatively, we see this struggle when analyzing our members’ data – across the board, no particular ACO is knocking CCM compliance out of the park. Our findings coincide with data from CMS showing that only 275,000 of an estimated 35 million Medicare beneficiaries who would qualify for the CCM program received services in 2015.
For those unfamiliar with CCM, the program allows providers to proactively manage chronically ill patients’ health outside the normal office setting and be reimbursed for those services, which have typically been provided without compensation. At a 30,000-foot level, here’s how CCM works:
- Providers must deliver at least 20 minutes of non-face-to-face, chronic care services per month.
- The average reimbursement is $40.00 per enrolled patient per month.
- CCM components must include a comprehensive care plan, medication reconciliation, transition of care, care coordination between providers and 24/7 access to urgent care for patient
As mentioned above, we know this is hard for ACOs, but it’s worthy of conversation now because CMS has made several changes to CCM billing in the 2018 Final Rule — specifically for rural health clinics (RHCs) and federal qualified health centers (FQHCs), and these changes may make it a little easier to bill and get reimbursed for CCM. At a high level, the changes take into account for the differences between the Medicare Physician Fee Schedule and RHC/ FQHC payment methodologies and allows for RHCs and FQHCs to use a new code — HCPCS G0511 (General Care Management Services), whenever the requirements for CPT 99490 (20 minutes or more of CCM services), CPT 99487 (at least 60 minutes of complex CCM services) or HCPCS G0507 (20 minutes or more of behavioral health issues services) are provided. Additionally, CMS made an amendment to reimbursement for CCM for RHCs and FQHCs specifically – based on 2017 rates, the changes would result in an increase from around $40 to $60.
For ACOs without FQHCs and RHCs in their network, we have observed one of our members in particular that has adapted their CCM strategy to outsource these services and has seen a 200% increase in CCM compliance in the past 12 months as a result. Given the labor intensity associated with CCM, services like ChartSpan, Wellbox and ThoroughCare have started to become more widely used by ACOs.
We’d love to hear what other ACOs are doing to try and increase CCM compliance – feel free to comment below and share your best practices with us and others!