Happy belated Passover and Easter, and thanks again to our practices serving patients in these trying times.
To help with any financial needs arising from deferred visits and other reduced revenue during this crisis, we wanted to share tips/guides/links to the following government and CMS support programs (details below).
CARES Act Provider Relief Fund
CMS Accelerated Payment Program
SBA Paycheck Protection Program (PPP)
SBA Economic Injury Disaster Loan (EIDL)
1. The CARES Act Provider Relief Fund ($30B) supports healthcare-related expenses or lost revenue attributable to COVID-19. This is relevant to the lost revenue some of our primary care partners have experienced due to telehealth and/or postponed visits resulting from COVID-19. HHS has made clear that this program provides “payments, not loans, to healthcare providers”, unlike the Advance Payment Program below. Amounts paid to providers are determined by their %age of the total 2019 FFS reimbursements ($484B), multiplied by $30B. Payment will be made via ACH in most cases, via UnitedHealth Group. More information here.
2. Medicare has expanded the Accelerated and Advance Payment Program ($34B already approved) to ensure providers and suppliers have the resources needed to combat the pandemic. The streamlined process implemented by CMS for COVID-19 has reduced processing times for advance payments to 4-6 days, down from 3-4 weeks prior. If interested, please see this guide on how to submit an advanced payment request.
3. PPP: As part of the US Government’s pandemic relief, small businesses under 500 employees can apply for the Paycheck Protection Program, which extends a 1% interest, 2 year, forgivable loan in the amount of 2.5X monthly payroll/rent/mortgage interest expenses. More information can be found here at the SBA, but loans must be applied for at banks and non-bank lenders. Fountainhead, a non-bank lender, is one option if your bank is not accepting applications (apply here).
4. EIDL: SBA’s Economic Injury Disaster Loan (EIDL) offers companies under 500 employees a ~3% loan for up to 30 year term. Use of proceeds varies from sick leave to increased costs from supply chains affected. NOTE: You can apply to both the EIDL and PPP loans as long as the use of proceeds don’t overlap. More information here at SBA, and you can apply directly via the SBA here.
If CircleLink can help your practice by driving more revenue with reimbursable remote care programs (CCM, RPM), or with anything else, please reach out to haziq@circlelinkhealth.com.
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We remain supremely impressed by all our customers and healthcare workers exhibiting courage and resolve in these times. Whether practices are transitioning to tele-health in days flat or staff is re-training for hospital duty, we at CircleLink are grateful for them and the opportunity to be helpful.
On our side, re: Chronic Care Management (CCM), we’re seeing record patient enrollment numbers (~2x usual rates) due to patients understanding the need to coordinate care from home.
Also, there’s co-pay waiver news that may further boost enrollment for preventive programs: Tele-health co-pays can now be waived during the crisis, including for CCM, i.e., the waiver applies to “monthly remote care management, and monthly remote patient monitoring.” (Source: OIG FAQ Q1 and OIG statement waiving tele-health co-pays here)
Finally, re: Tele-health, we’d like to share below links which Dr.s have told us were helpful, although many practices are already up and running with remote visits:
In October, we posted about Medicare’s proposals for drastic improvements to Chronic Care Management (CCM) and other reimbursable programs like Remote Physiologic Monitoring (RPM), starting Jan. 2020.
Below, we explore the most impactful changes that practice leaders need to know.
Table of Contents:
1. Transitional Care Management (TCM) a. Fee increase b. Now allows other care management to be concurrently billed with TCM
2. CCM a. New code for each additional 20 minutes of care management beyond 20 minutes per month b. Complex CCM removes requirement for ‘substantial care plan revision’
3. Remote Physiologic Monitoring (RPM) a. New code for each additional 20 minutes of care management beyond 20 minutes per month b. Allows off-site care managers
4. New “Principal Care Management” (PCM) codes for patients with 1 ‘serious chronic condition’
1. TCM (Transitional Care Management) fee increase
As discussed in our last post, Medicare found that i) TCM utilization is still low compared to the number of Medicare discharges and that ii) TCM services reduced readmission rates, lowered mortality, and decreased health care costs.
To increase clinicians’ use of this valuable care program, Medicare is increasing reimbursements for TCM codes by as much as 12% and allowing care management codes like CCM (ex: CPT99490) to be concurrently billed with TCM: “we are finalizing… to allow concurrent billing of the care management codes currently restricted from being billed with TCM. This includes allowing concurrent billing of TCM with the 14 codes specified in Table 20, as well as CPT codes 99490 and 99491” (page 397)
2. Chronic Care Management (CCM)
Medicare again referenced data showing cost savings from CCM and reiterated their intention to responsibly expand CCM to appropriate patients. The two key proposals discussed in our last post were implemented. That is, additional care management time beyond 20 minutes can be reimbursed, and, Complex CCM no longer requires a significant care plan change. However, some minor coding changes were made in the final ruling:
a. The finalized code for each additional 20 minutes of care, G2058, will take the place of the proposed code “GCCC2”, and be billable on top of CPT 99490
Reimburses “each additional 20 minutes” of needed non-face-to-face follow-up care beyond the first 20 minutes per month.
0.54 RVU
G2058 can be billed concurrent to 99490, up to 2 times for the same patient per month
Medicare: “we are finalizing GCCC2 (the add-on for non-complex CCM clinical staff time), henceforth referred to as G2058, because this code addresses what we believe is an important gap in the current code set” (page 404)
b. Complex CCM codes no longer require “substantial care plan revision”. This requirement limited care for many folks requiring 60+ minutes of care coordination where there may not be a ‘substantial care plan revision’ as defined by CMS. To prevent overuse, Medicare is keeping the “moderate or complex medical decision making” requirement in place.
3. Remote Physiologic Monitoring (RPM) has a new 20 minute code and allows remote care managers
Medicare finalized the 2 key changes for Remote Physiologic Monitoring (a set of ~$60-$120 reimbursements, per patient per month, for monitoring+managing vitals like blood sugar/pressure).
First, Medicare finalized a new add-on code, CPT 99458, which pays 0.61 RVUs for an additional 20 minutes of clinical care management time relating to vitals monitoring. This 99458 code is in addition to the existing CPT 99457 code for the first 20 minutes.
Second, Medicare now allows general supervision for the CPT 99457 and 99458 codes, meaning remote care teams may provide this care. Specifically, they ”designate both CPT code 99457 and CPT code 99458 [to be] care management codes as defined in § 410.26(b)(5) of our regulations.” (page 431) This means that off-site care managers like CircleLink’s 100% RNs can provide the “Remote physiologic monitoring treatment management services”, whereas in 2019 the clinical staff providing services needs to be on-site in the same facility as the supervising provider/doctor.
4. New “Principal Care Management” for patients with 1 ‘serious chronic condition’
Medicare finalized 2 codes (below) relating to “Principal Care Management” to cover patients with a single serious chronic condition. This enables care management for patients who don’t qualify for CCM’s 2-condition requirement.
G2064 (1.45 RVUs for 30 mins of Dr. time)
G2065 (0.61 RVUs for 30 mins of clinical staff time)
However, it should be noted that G2065 requires 30 minutes of staff time while paying the same RVU as CCM pays for 20 minutes.
These codes require 1 condition for which a patient has received care for 3-12 months, which puts patient at risk for hospitalization, or has resulted in a recent hospitalization.
While a practitioner (Primary Care or Specialist) may bill PCM concurrent with RPM, they may not bill PCM with other care management codes (e.g., CCM) for the same patient/month.
Finally, while PCM’s requirements mirror CCM’s, there are two key differences:
Care Plan: PCM requires a “disease-specific” care plan vs. CCM’s comprehensive care plan
Documentation: PCM requires that communication/care coordination “between all practitioners furnishing care to the beneficiary… be documented by the practitioner billing for PCM in the patient’s medical record.” (page 420)
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Is your practice prepared to take advantage of these adjustments to CCM, RPM and other care management programs? CircleLink demystifies the reimbursement process and can assess if your practice is a fit for increasing revenue/patient health.
NOTE: FQHCs/RHCs may not bill for the new CCM and RPM codes. However, patients meeting PCM requirements are billable under the G0511 FQHC/RHC care management code.
https://secureservercdn.net/104.238.69.231/eb5.896.myftpupload.com/wp-content/uploads/2019/11/New-CCM-Codes-Approved.jpg?time=1591413952582900raphhttps://www.circlelinkhealth.com/wp-content/uploads/2019/04/logo-2.pngraph2019-11-05 06:27:132020-03-16 09:39:50APPROVED: New Care Management/RPM/CCM Codes for 2020
Medicare recently (July 2019) proposed major improvements to Chronic Care Management (“CCM”) and other reimbursable programs, effective Jan. 2020 (source proposal). These changes have the potential to significantly improve practice revenue and patient health (plus lower systemic costs).
Below, we’ve outlined the most impactful reimbursement proposals primary care providers and practice leaders need to know about for 2020.
Check back here in November, when the Medicare proposals are finalized, for an update on what will be included in the final 2020 fee schedule!
Key proposals:
1. TCM (Transitional Care Management) fee increase
2. CCM a. New code for each additional 20 minutes of care management beyond 20 minutes per month b. Complex CCM removes requirement for ‘substantial care plan revision’
3. Remote Physiologic Monitoring (RPM) now allows remote/off-site care managers
4. New “Personalized Care Management” for patients with 1 ‘serious chronic condition’
1. TCM (Transitional Care Management) fee increase
TCM incentivizes physicians to follow-up with a patient post-hospital discharge to ensure the patient stays healthy/avoids re-hospitalization. There were nearly 1.3 million TCM claims in 2018, up from 300,000 in 2013, TCM’s first year. However, an analysis by Bindman and Cox found that utilization is still low compared to the number of Medicare eligible discharges. More importantly, the analysis found that beneficiaries who received TCM services demonstrated reduced readmission rates, lower mortality, and decreased health care costs.
To increase clinicians’ use of this valuable care program, Medicare is increasing reimbursements for the codes by as much as 12%:
RVU for CPT 99495 increase to 2.36 (from 2.11)
RVU for CPT 99496 increase to 3.1 (from 3.05)
2. Chronic Care Management (CCM)
In its recent proposal, Medicare references data showing costs savings and increased patient/provider satisfaction attributable to CCM. Medicare then proposes new codes and changes in the hopes of expanding the program.
a. Most significant is the proposed code “GCCC2” (0.54 RVU) which reimburses “each additional 20 minutes” of needed non-face-to-face follow-up care beyond the first 20 minutes per month. This will allow higher quality follow-ups with patients needing time-consuming care management. For example, CircleLink’s own RNs may spend over 60 minutes in a month coordinating care with a single patient where complex approvals and logistics may be needed, e.g., delivery of medical equipment like an oxygen tank. Other times, a medication reconciliation in addition to detailed patient education/follow-ups may exceed 20 minutes per month but are nonetheless necessary to improve patient health and compliance. This new code (GCCC2) will make sure practices are incentivized to give patients all the follow-up care they need, not just 20 minutes per month.
b. Separately, Complex CCM codes no longer require “substantial care plan revision”. This requirement limited care for many folks requiring 60+ minutes of care coordination where they may not be a ‘substantial care plan revision’ as defined by CMS. To prevent overuse, Medicare is keeping the “moderate or complex medical decision making” point in place.
3. Remote Physiologic Monitoring (RPM) would allow remote care managers
Remote Physiologic Monitoring (~$60-$120 per patient per month for monitoring+managing Blood Pressure/Blood Sugar and other vitals readings remotely) has been affected in 2 key ways. First, there’s a new add-on code (994X0, 0.5 RVUs) for an additional 20 minutes of clinical care management time relating to vitals monitoring, on top of the existing CPT99457 code for the first 20 minutes.
Second, the proposal puts both CPT99457 and this new add-on code under general supervision rather than direct supervision. This means that off-site care managers like CircleLink’s 100% RNs can provide the “Remote physiologic monitoring treatment management services”, whereas in 2019 the clinical staff providing services needs to be on-site in the same facility as the supervising provider/doctor.
4. New “Personalized Care Management” for patients with 1 ‘serious chronic condition’
Finally, a new “Personalized Care Management” code – GPPP2 – covers patients with a single serious chronic condition. This opens up PCM for those who don’t qualify for CCM’s stringent 2-condition requirement. However, it should be noted that this code requires 30 minutes of staff time while paying the same amount as CCM pays for 20 minutes.
GPPP2 will require 1 condition for which a patient has received care for 3-12 months, which puts patient at risk for hospitalization, or has resulted in a recent hospitalization. Insofar as we can say now, GPPP2 may be billed by a specialist in parallel with a Primary Care Provider doing CCM. Terms and payment amounts will be roughly the same as CCM (~$42 per patient per month), except that the proposed 2020 fees appear to require 30 minutes of clinical staff time instead of 20 minutes for CCM.
Is your practice prepared to take advantage of these adjustments to CCM, RPM and other care management programs? Are you already doing your best with existing CCM and BHI programs? CircleLink can help demystify the reimbursement process and assess whether your practice is a fit for increasing revenue and patient health through these reimbursable services.
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In 2015, Medicare launched Chronic Care Management (CCM), a program incentivizing practices to follow up with chronic condition patients outside the office between visits. Other programs followed to improve health, like Behavioral Health Integration (BHI), which focuses on follow-up between visits for patients with mental conditions. These programs provide a significant financial incentives to providers, up to ~$42-$80 per patient per month, or up to $200K+ per provider annually.
However, despite these programs’ health improvements and systemic cost savings, many doctors and their staff lack the infrastructure and extra staff to implement them.
CircleLink Health conducted a survey of 51 primary care providers and 9 cardiologists to determine their general level of CCM awareness and preparedness. The results suggest that while physicians believe their practices could benefit from CCM/BHI, they struggle to implement these programs effectively. In fact, despite 77% of physicians polled being aware of Chronic Care Management’s launch in 2015, only 12% reported they are billing for CCM consistently.
The Challenges of Treating Patients with Chronic Conditions:
Patients with chronic illnesses can be time-consuming for practices. For instance, follow-up calls that can ensure these patients take their medication and understand their doctors’ instructions take hours per week. Specifically, our poll showed most doctors’ staff spending between 8-20 hours per week on such follow-ups. (62% reported their staff spent 8+ hours each week on such calls.)
Even with the above time being spent on follow-ups, only 7% of physicians polled reported their staff always having more than enough time to call their chronic condition patients in between appointments.
Which makes sense: Office staff are crucial to the day-to-day operations of practices. Spending hours on the phone with these chronic conditions patients can disrupt their workflow. Having new resources funded by CCM or other preventative programs can free up staff to focus on patients who need attention in-office, among other priorities.
The Challenges of Implementing CCM Programs:
Although preventative care programs like CCM seem to be a perfect solution to these challenges, our survey found that physicians struggle with finding the needed staff time, resources and infrastructure.
Per the below chart, the three most cited barriers are (among the 65% of respondents who hadn’t launched):
Lack of staff time required for new revenue programs
Difficulty in understanding complex program requirements
Unfamiliarity with these programs’ reimbursements
In addition, finding time to research how to implement a CCM program can be difficult for physicians and staff who fill their entire workdays with clinical matters. The complex regulatory environment and resulting operational needs surrounding these programs/reimbursements makes this work time consuming.
CircleLink Health Can Help Your Practice Implement a CCM/BHI Program:
Luckily, CircleLink Health provides the technology, telephone RNs and guidance physicians need to implement successful preventive care programs with zero additional staff or upfront costs. From full-service CCM/BHI solutions to customized/targeted offerings based on practices’ needs, CircleLink can help. Interested in learning more? Send an email to Haziq@CircleLinkHealth.com.
https://secureservercdn.net/104.238.69.231/eb5.896.myftpupload.com/wp-content/uploads/2019/09/Circle-Link-Health-Dr-Suvey-Blog-Image.jpg?time=1591413952582900raphhttps://www.circlelinkhealth.com/wp-content/uploads/2019/04/logo-2.pngraph2019-09-18 09:31:052020-03-16 09:43:45Dr. Survey: What’s stopping Chronic Care Management and other programs
A chronic care management (CCM) or behavioral health integration (BHI) program has great potential benefits for patients, but requires considerable investment of resources and administration across a large number of staff. These hurdles have contributed to the 2-3% adoption rate of CCM in the 1st two years of the program*. On the BHI side, a brief from the Institute for Clinical and Economic Review (ICER) showed that BHI is more effective at promoting improved health outcomes than traditional care, but costs between $20 to $3,900 per patient depending on location and individual patient needs.
The good news is that the extra revenue that a practice receives from BHI/CCM programs, which is roughly $40-80 per patient per month, can offer significant profits and ROI, if managed properly. This is where the benefit of prior CCM/BHI experience comes in.
There’s also additional program value in terms of health, quality of life and savings to Medicare. For example, a report by Mathematica from 2017 found that CCM services (for the sample studied vs. a control group) reduced net Medicare costs by over $30M.
So if it makes sense for your institution to offer a CCM / BHI program, should you run it yourself, or should it be outsourced? Today we’ll help you make this decision by walking you through the reimbursement and profitability of CCM and BHI programs.
Data on reimbursements
The reimbursement for CCM varies considerably between states, ranging from $39 to $57 per patient per month. The feasibility of administering a cost-effective CCM / BHI program therefore changes depending on the cost, effectiveness and efficiency of overheads. Wondering what your reimbursement is? Drop us a line at Haziq@CircleLinkHealth.com for access to our comprehensive region by region reimbursement data set.
Profitability drivers and example calculation
1. Staffing
Firstly (and most importantly, given high staffing costs associated with care) is the fixed overhead costs or vendor costs for staffing relative to the rate of reimbursement. CCM/BHI requires co-ordination and management of a team, including roles such as primary care physician and care manager.
When considering staffing costs, also take into account all of the staffing hours that are required on top of the 20-40+ minutes per patient per month of direct patient contact. This includes time for issues like determining patient eligibility, enrolling patients (and documenting enrollment), preparing care plans, tracking approval of those plans by a doctor, and presenting care plans to patients. There will also be considerable time for non-call time activities like scheduling calls, documenting calls, managing/training care coaches, and trying to contact unresponsive patients. Finally, there are also time costs in determining which patients can be billed for and preparing their billing information, as well as the usual staffing costs of vacation and sick days.
In terms of BHI programs specifically, behavioral health specialists are an important group to consider, as they may need to be hired from outside the usual streams of staff acquisition. Depending on patient needs, behavioral health specialists could come from a range of backgrounds with different associated levels of cost including social work, nursing, psychiatry, psychology, substance abuse support, or counseling. As with other programs, the costs for staffing will vary depending on region, and also on whether these staff are permanently employed or are agency workers.
2. Number of patients enrolled and their duration on program
A second key consideration in terms of profitability is the reimbursement, driven by i) duration of the program for each patient, ii) the number of patients enrolled and iii) the number of enrolled patients reached each month. As mentioned in the introduction, a CCM/BHI program can be expensive to set up without outside help. To offset this initial expense and the ongoing fixed costs of an in-house program, practices must soberly estimate if they have the HR and technology to efficiently execute on each of parts i), ii) and iii) above.
A typical CCM patient, as described in the Mathematica report, receives services for between four and ten months. In the case of practices using CircleLink to avoid such fixed cost risk, patients are typically on the CCM/BHI program for somewhere in the range of eight to twelve months and 90% of active, reachable patients may be billed each month, as they are given care by high level staff like registered nurses. CircleLink has found that using higher level registered nurses keeps patients on the program longer, vs. using medical assistants.
3. Total profitability
The total profitability of the program can be calculated relatively simply: consider the patient-months billed times the reimbursement rate, then subtract total costs such as staffing costs, employment taxes, real estate and facility management costs, and the overhead costs of the team doing care coaching.
For example, consider a Licensed Practical Nurse working on a CCM program operating in New York. The staffing costs of such a position are around $58,000 per year, or around $70,000 in total including overhead costs and taxes. With a NYC reimbursement rate of $49 per month, as shown in our reimbursement table, you can see that the nurse in question would need for bill for 120 patients per month just to break even.
When you consider all of the staff work required in addition to the care coaching call time, plus the LPN being pulled into non-coaching facility duties, this level of billing may not be feasible. Achieving a higher level of patient billing for a return on investment may be even further afield.
CircleLink can help
If you are looking for support in the management of your own CCM / BHI program, then CircleLink can help. Our services have zero upfront costs, can launch in 2-4 weeks and are always profitable (you only pay fees for billable patients). Care coaching is handled by our team of 100% registered nurses so you needn’t worry about hiring, training, or scheduling staff to follow up with patients between visits. And we offer a dedicated expert account manager to walk you through the process and answer any questions. Our service is trusted by both large health system practices and smaller clinics nationwide. Call us today at 917-999-6560 to request a demonstration and learn how we can help you offer the best care to your patients.
*for 2015-2016, according to CMS’s 2017 Physician Fee Schedule and assuming ~70% of Medicare beneficiaries have the 2+ chronic conditions needed for eligibility
https://secureservercdn.net/104.238.69.231/eb5.896.myftpupload.com/wp-content/uploads/2019/05/image9.jpg?time=159141395213331999raphhttps://www.circlelinkhealth.com/wp-content/uploads/2019/04/logo-2.pngraph2019-05-01 08:41:092020-03-16 09:42:57What's My Reimbursement and Profits for CCM?
