Chronic Care Management (CCM) services have many benefits – like saving Medicare’s money, improving health, and generating extra revenue for healthcare providers.

Unfortunately, designing and implementing an effective CCM program is difficult, leading to low program adoption. For example, one study found that only 0.65% of 1.7 million potentially eligible individuals received CCM services in New England.

Below, we explain the key CCM challenges and how CircleLink solves them for our customers.

Challenges Explored:

  • Identifying eligible patients
  • Educating patients and getting consent
  • Managing a team of nurses and care coaches
  • Call scripts and care plan content
  • Scheduling and managing calls
  • Time and activity tracking
  • Medicare billing selection and reports
  • Audit support and reports

Identifying eligible patients

Manually checking thousands of practice patients for Medicare/Medicare Advantage insurance and CCM program eligibility is tedious work. Without a service like CircleLink to automate the process, it can become an expensive time sink.

Educating patients and getting consent

A medical practice must have patient consent before offering or charging for CCM services. This consent doesn’t have to be written – verbal works fine – but it has to be documented in a patient’s records. Moreover, the patient has to be made aware of things like potential cost sharing and individual requirements in order to grant qualified consent. The additional time needed to address this at busy practices leads to low or near-zero CCM enrollment.

One solution is having CircleLink’s trained ambassadors take care of education and consent. They’ve helped onboard thousands of patients in the past and can do the same in your practice, freeing you up to take care of in-office activities.

Managing a team of nurses and care coaches

Patients expect and deserve seamless, uninterrupted care. Unfortunately, medical professionals are only human – which means that nurses/CCM Care Coaches go on vacation, switch practices, call in sick, and miss work for various reasons.

Now, how can you make sure patients are regularly called for CCM coaching despite any staffing changes? By managing nurses and care coaches effectively. This usually consists of a 2-pronged approach:

  1. Effective systems and processes. For example, it’s often possible to stay on top of unexpected situations by having a list of trusted temps that can stand in for a nurse – or by having an overtime protocol that lets you delegate extra work to existing staff.
  2. Human oversight. Someone needs to be in charge of making sure CCM runs smoothly year-round. This can be a separate job and employee, a team effort, or a new responsibility for someone already working at a practice.

Once both are in place, keepings things running is easy – but getting to that point is often anything but. The cost and overhead involved are also considerable, creating financial risk in case billable patient revenue does not cover costs.

CircleLink eliminates financial risk and provides these management services all for a flat price per billable patient. We charge less than the reimbursement, so customers don’t have to worry about the program losing money.

Call scripts and Care Plans

CCM processes must follow Medicare guidelines. This means creating care plans and call protocols that miss nothing and ensure compliance.

Developing these and teaching staff to work with them can be time-consuming. Things get even harder if you’ve never done CCM before and have no point of reference for how to do things right. For better or worse, though, you need compliant care plans and call scripts.

CircleLink has created best-in-class content with our top clinician leaders, including Abigail Roaquin, BSN, RN, Dr. Gregory Taylor and Dr. Scott Schissel.

Call scheduling

Once a CCM program gets going, it’s important calls are assigned to the right patients and care coaches at the right time, efficiently. Otherwise, many practices will find that the fixed expense of their CCM staff exceeds the CCM reimbursements. You’ll need to monitor CCM operations to make sure things run smoothly. CircleLink has proven operational skills here (case study).

Time tracking

Your in-house team’s activities will need to be recorded and logged. Doing this manually is difficult. The next most common alternative – doing it with a spreadsheet such as Excel or Google Docs – can be unreliable, frustrating, and time-consuming.

One solution is to use CircleLink’s system which automatically tracks all activities and time to the second. Alternatively, you might want to write your own software system from scratch – but that requires time, money and expertise that may not be a core competency to a medical practice.

Medicare billing selection and reporting

To figure out which patients to bill for each month, you need to tabulate the time spent and type of care/interactions received by your CCM patients. You’ll then need to review that information to determine which patients you can compliantly bill for.

As mentioned in the prior section, tracking CCM activities manually, or with a spreadsheet, can be unreliable for management and frustrating for staff. Moreover, manual record-keeping can put a practice at risk during Medicare Audits.

That’s why many practices use a Chronic Care Management platform like CircleLink. CircleLink determines which patients to bill for (each month) using programmatic and manual checks, as we’ve done for tens of thousands of CCM claims.

With zero effort on the practice’s part, we deliver a detailed list of all billable patients. We also include information needed for billing, like billing provider, ICD-10 codes and other items.

Audit support and reports

Once you’ve serviced and billed your patients, you’ll have to provide paper trails and documents in case of a Medicare audit. This can be problematic if you rely on your own internal mechanisms to manage CCM.

CircleLink can help with our 1-click, detailed Audit Report with second-by-second records of each interaction with each patient each month.

If you don’t have an equivalent system, you may want to consider implementing one.


As you can see, there’s a long list of difficulties clinics face when implementing CCM.

The good news is that all of them can be solved by hiring extra staff and developing software internally. If you don’t want to spend time and money solving these problems in-house, you can also consider partnering with CircleLink for chronic care case management solutions.

If you’d like to learn more about how we can help your specific practice – we’re here for you! Please email or call 917-999-6560 for a free consultation.