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Chronic care management: New risks, new opportunities

Last week, the Senate Finance Committee passed a bipartisan bill aimed at strengthening and improving health care outcomes for chronically ill Medicare beneficiaries. The Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 was introduced April 6, and was unanimously approved by the committee in a 26-0 vote on May 19.

The unanimous passage of the CHRONIC Care Act by the committee demonstrates the importance of addressing the challenges of improving the quality of care while reducing the significant cost of treating chronically ill Medicare beneficiaries. More than 90 percent of each Medicare dollar goes toward caring for seniors who have two or more chronic conditions, Senator Ron Wyden (D-Oregon) said in a statement prior to the vote. Among other things, the legislation would allow Medicare Advantage plans to develop benefits specific to chronic conditions including cancer, diabetes, and Alzheimer’s disease. It would also promote the use of telehealth technology, which would allow more chronically ill Medicare beneficiaries to receive care at home.

The passage of the CHRONIC Care Act along with recent efforts by the US Centers for Medicare and Medicaid Services (CMS), which has eased the Chronic Care Management (CCM) program requirements for providers, reflect a strong commitment to improve the treatment for the chronically ill Medicare population and incentivize health care providers everywhere to play their part to advance coordination of care.

Reimbursement for CCM services was conceived as part of the federal government’s emphasis on decreasing the cost of medical care, and reducing readmissions, by enhancing the coordination of primary care efforts for Medicare beneficiaries. Since its inception by CMS in 2015, there has been progressive adoption from providers in response to the new opportunity for reimbursement to manage chronically ill patients who have two or more chronic conditions.1

CMS has released in its final rule for the Calendar Year 2017 Medicare Physician Fee Schedule (MPFS) updates to payment policies, payment rates, and quality provisions for services furnished on or after January 1, 2017.

Although the industry’s initial response to the opportunities created by CCM reimbursement could be described as cautious, the creation of new codes and simplification of billing requirements, combined with the advancement of available technological solutions, will likely make it easier for providers to capitalize on the monitoring and case management of patients who have chronic conditions.

With the number of chronically ill beneficiaries receiving CCM services projected to grow beyond 513,000 in 20172 and the associated growth in potential reimbursement, it is easy to see why the development and implementation of a successful CCM program is appealing to many health care systems. Although appealing, enforcement agencies are paying close attention to developments.3

In order to inventory, assess, and prepare for the compliance risks resulting from providing these services, compliance leadership should work closely with other organizational leaders and key stakeholders to understand the broad clinical, operational, financial, organizational, and technological implications that these regulatory changes have across their organizations.

The elements of the MPFS final rule, which may encourage increased industry participation, include:

  • Simplification of CCM qualifications for reimbursement
  • Creation of payment for complex CCM
  • Allowance for payment for care plan development
  • Payment for non–face-to-face prolonged evaluation and management (E/M) services

These significant changes are intended to provide greater reimbursement for patients who require higher levels of medical decision-making, reduce administrative burden, and align CCM more closely to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (see Figure 1).

Chronic care management


New codes, new opportunities, new risks

The complexity and cumbersome nature of the original service elements and billing requirements for Medicare reimbursement for CCM services caused many practitioners to voice their concerns and frustrations. Taking the practitioner feedback into consideration, the MPFS final rule modifies current requirements and intends to simplify processes in hopes of increasing the number of beneficiaries who have their chronic conditions coordinated and monitored by eligible providers.

Some key elements from the MPFS final rule that compliance professionals should take note of include:

  • The MPFS final rule adopted Current Procedural Terminology (CPT) language, which states that a copy of the care plan must be given to the patient or caregiver and the care document(s) must be shared timely with other practitioners.
  • CMS did not designate a specific format for the care plans as a condition of payment.4
  • The final rule requires billing practitioners to communicate with beneficiaries, informing them of certain elements, previously established through rulemaking, including the availability of CCM services, that only one practitioner can furnish CCM services and be paid for these services during a calendar month, and that the beneficiary has a right to stop CCM services at any time. Beneficiaries can agree to receive these services on a monthly basis, as cost-sharing provisions apply.
  • The final beneficiary consent requirements do not affect any written agreements that are already in place for CCM services; practitioners can still elect to obtain written consent and may choose to include a notation within the medical record of the beneficiary accepting or declining CCM services.5

Based on commenters’ feedback, the new, separately payable, CPT codes of 99487 (Complex CCM services – 60 minutes) and 99489 (Complex CCM services – additional 30 minutes) were finalized for 2017. These separately payable codes for complex CCM services are intended to support care management for more complex and time-consuming cases of beneficiaries with multiple chronic conditions. Also, an add-on code G0506 (care planning) has been created and should be listed separately and incrementally to the primary service, when applicable.6 It is also important to note that the final rule states that a CCM initiating visit is only required for new patients or patients not seen within the year prior to commencement of CCM. The goal of this provision is to allow practitioners to initiate CCM services with recently seen beneficiaries, for the first time, without furnishing a potentially unnecessary E/M visit.7

Key compliance considerations

The Health and Human Services Office of Inspector General (OIG) will be keeping a close eye on payments for CCM. In fact, as stated in their 2017 Work Plan, the OIG intends to review whether payments for CCM services were issued in accordance with Medicare requirements.8

Therefore, compliance professionals should be aware of the important regulatory changes for 2017 and incorporate needed risk mitigating activities into their compliance plans. Determining patient, provider, and service eligibility; establishing clear policies and protocols for CCM operating models; and developing and delivering effective training remain the foundational pillars for building a CCM program that is positioned for success and can integrate into broader population health strategies and value-based care objectives.9

Organizations preparing to design and implement a CCM program should consider the following strategic questions:

  • How will we “identify” and strategically target eligible beneficiaries who qualify for participation in a CCM program?
  • How will we consistently and effectively “inform” these identified patients of our CCM program and its value to them?
  • How will we maintain compliance with existing requirements while operating a nimble CCM program capable of growth and continuous improvement?
  • How will we monitor regulatory developments related to CCM, prepare for the necessary changes, and avoid unintended consequences?
  • How will we prepare for and respond to post-payment government audits in order to protect the CCM reimbursement that we’ve received?

Final thoughts

By simplifying the billing rules for CCM, the 2017 MPFS final rule creates new, unique opportunities for organizations that choose to implement CCM programs. It is expected that industry participation will likely increase as a result, leading to potential associated reimbursement growth for CCM services.

Adoption of a CCM program without consideration for all requirements creates considerable revenue risk and an increased focus on post-payment reviews will require compliance professionals to remain vigilant on changes to these requirements and their evidence of compliance.

By understanding and adhering to the requirements while supporting the innovative and evolving delivery of and billing for CCM services, compliance plays an important role in supporting the successful delivery of a CCM program.

2017 MPFS proposed rule, 81 FR 46207, published July 15, 2016.
2017 MPFS final rule, 81 FR 80244, published November 15, 2016.
2017 OIG Work Plan: NEW: Medicare Payments for Chronic Care Management.
2017 MPFS final rule, 81 FR 80251, published November 15, 2016.
2017 MPFS final rule, 81 FR 80250, published November 15, 2016.
2017 MPFS final rule, 81 FR 80244, published November 15, 2016.
2017 MPFS final rule, 81 FR 80245, published November 15, 2016.
8 Ibid, Ref #4
Peter A. Khoury: “Compliance challenges in new chronic care management code” Compliance Today, March 2015, pp 39-42.


Author bio

Ryan is a Senior Manager in Deloitte & Touche LLP’s Advisory practice, and has more than seventeen years of professional experience serving as a strategic advisor to the Health Care Provider industry, leading enterprise wide risk assessments and advisory engagements for large health systems and academic medical centers. This work includes managing all aspects of strategic, financial, operational, IT and regulatory compliance assessments for not-for-profit, private and public companies. Ryan has presented to multiple Health Care industry groups on the topics of compliance department strategy, enterprise risk management and strategies, risks and compliance related to the use of Electronic Health Record (EHR) technology and the implications of disruptive regulatory events such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).