The Critical Questions Your APCM Plan Needs to Answer

Advanced Primary Care Management (APCM) is an exciting opportunity — don’t blow it

Darshan Bachhawat
January 16, 2025

We see increasing excitement about Medicare’s new Advanced Primary Care Management (APCM) program. Done well, APCM could be transformative for primary care practices and their patients. APCM provides fee-for-service reimbursement for providers to deliver high-value, proactive care across entire populations. APCM will be a financial lifeline for physicians, enabling them to invest in staffing and services that will directly benefit patients.

But to see those benefits, you have to do APCM well.

A poorly-executed APCM launch will disrupt your operations and destabilize your finances. Worst of all, low-quality APCM will diminish the trust your patients have in your practice. You must have a thoughtful, comprehensive plan for your APCM program.

KEY TAKEAWAYS

Advanced Primary Care Management (APCM) and Chronic Care Management (CCM) are fee-for-service Medicare reimbursement programs. Both help providers invest in value-based care, but APCM is geared toward primary care.
Success in APCM means creating value for patients, providers, and Medicare. You need a well-thought-out plan to do this.
A comprehensive plan should cover patient identification, enrollment, care management, and billing.
You must also have a compliance strategy that supports excellent care and long-term financial sustainability.

Elements of a Strong APCM Plan

Care management contributes to better health outcomes and reduces the total cost of care (TCoC), two primary goals for CMS. APCM is a fee-for-service reimbursement program that creates incentives for providers to move toward value-based care.

Both Chronic Care Management (CCM) and APCM are intended to drive value-based outcomes, but APCM is generally better for primary care providers.

WEBINAR

Advanced Primary Care Management vs. Chronic Care Management

To learn more about APCM and CCM, watch our on-demand webinar. This comprehensive comparison will help you evaluate which program is the best fit for your practice.

If you want your APCM program to achieve long-term financial sustainability, consider 5 key elements of your plan:

Patient Identification
Patient Enrollment
Care Management
Billing
Compliance

Here are some questions you should think through. (Ideally, do this before you begin enrollment and patient consent!)

What Drives APCM Program Success?

A successful APCM program will create value for all stakeholders:

Your healthcare organization
Medicare (and taxpayers)
Your patients

In my last article, I explained that APCM success hinges on creating value for your patients. Many patients will have a cost sharing responsibility. To retain patients in APCM, your practice must deliver excellent care management at scale. But high-quality care management is just one of the pillars that drives APCM program success and financial sustainability.

Here are descriptions of each pillar, and some key questions you should ask as you develop your APCM plan.

1. Patient Identification

Currently, patients enrolled in Traditional Medicare are eligible for APCM. We expect Medicare Advantage plans will eventually reimburse practices for APCM. However, reimbursement may vary considerably compared to Traditional Medicare.

(For CCM, Traditional Medicare reimburses at $62.58 for 20 minutes of care. But Medicare Advantage plans reimburse anywhere from $0 or $2 up to $80 for that same 20 minutes. APCM reimbursement will likely show similar variation.)

As you think about identifying eligible patients, consider the following questions:

How many of your patients have Traditional Medicare?
For the future: how many of your patients have Medicare Advantage plans? (This may be more challenging to determine at the start of the year given churn.)
Qualified Medicare Beneficiaries have no cost-sharing but may be harder to reach. How many of those patients do you have? Do you have good channels and community partnerships to help engage them?
Can you segment your population by the number of chronic conditions?

This will help you understand potential utilization and reimbursement. It will also help you understand the cost-sharing burden for patients. Finally, planning ahead for Medicare Advantage reimbursement will help you expand your program in the future.

2. Patient Enrollment

Patient enrollment is more complex than you might think! Medicare seems to expect every patient to be enrolled, which sounds great:

“We anticipate that a practitioner using the advanced primary care model will bill for APCM services for all or nearly all the patients for whom they intend to assume responsibility for primary care.”

– Medicare 2025 Physician Fee Schedule

But it’s not that easy. You will need a strategy, plan, and tools to manage enrollment.

You can enroll patients during an initiating visit, such as an annual wellness visit. However, Medicare rules give you the flexibility to enroll existing patients proactively through outreach:

“An initiating visit is not needed: (1) if the beneficiary is not a new patient (has been seen by the practitioner or another practitioner in the same practice within the past three years) or (2) if the beneficiary received another care management service (APCM, CCM, or PCM) within the previous year with the practitioner or another practitioner in the same practice.”

– Medicare 2025 Physician Fee Schedule

(Note that participating in the ACO REACH Model, the Making Care Primary model, or the Primary Care First model will satisfy the initiating visit requirement for assigned beneficiaries.)

What are your enrollment goals? How quickly do you need to get to critical program mass? How will you capture and document patient consent?
How many of your existing Medicare patients will not require an initiating visit? This will determine your ability to do mass outreach and rapid enrollment at scale. (Do you have the tools you will need to facilitate that outreach?)
How many of these patients are already enrolled in CCM? How will you manage that transition?
Are you able to strategically sequence patient outreach by segment?

Consider how you will educate patients during the enrollment process:

Do you have a comprehensive approach to patient education and marketing? You can control in-office communication, but what marketing channels can you leverage to encourage patients to sign up outside of the clinic?
What kind of patient education do you need to do before you launch your APCM program? How will you communicate cost-sharing requirements in a way that helps patients understand program value?
How will you handle patients who have caregivers with a power of attorney for healthcare-related decisions?
Other healthcare organizations in your market are also planning to do APCM. Are you ready to educate, engage, and enroll as much of your target market as you can – before your competitors do?

Again: “Enroll and bill for every patient” may sound great. But it’s not that easy.

3. Care Management

High-quality care management is the essence of APCM. Good care drives outcomes and creates value for patients – critical when many patients will have cost-sharing responsibility.

Consider how you might scale quality care:

With APCM, there is no time-based component. (Time alone does not equate to better or more care management.) How could removing this restriction enable you to deliver better and more efficient care? How will you meaningfully engage all your patients (more than once a month!) to promote better clinical outcomes?
Do you have dedicated care managers supporting your APCM program?
Are your care managers able to support 1000s of patients simultaneously with personalized, consistent, and high-quality care? For CCM, we expect a care manager to have a panel of 500 patients. For APCM, we expect a care manager to handle 1,000 or even 2,500 patients.
Do your care managers have automated tools (including AI support) to help manage documentation and administrative tasks, enabling them to spend more of their time caring for patients? How will you keep your staff operating at the top of their licenses?
If you have an at-scale program where you are taking care of 1000s of patients, do you have the tools to ensure high quality, consistent care across all your care managers? Who will review their work? How will you perform quality control?
What tools will enable your care managers to quickly understand a patient’s context, including previous conversations, medical history, and progress toward care plan goals?
How can you enable your care managers to efficiently access reference materials, tailored to your patient’s chronic conditions and other medical needs?

Consider how you will integrate APCM services with the rest of the work your organization does:

How will you align between-visit care with other protocols and workflows to prevent duplicate work? When done effectively, APCM should streamline administrative work. For example: creating easier channels for scheduling preventative services such as annual wellness visits.
Healthcare organizations running high-quality, large scale Phamily CCM programs see care shift from ED and inpatient settings to outpatient settings. APCM will likely accelerate this shift. Are you equipped to see more patients in the office?
When your care managers identify issues that require intervention, how will you ensure patients are directed to the appropriate level of service? And how will care managers engage with APPs and physicians in ways that decrease rather than increase provider workload?

Remember, many patients will have cost-sharing. They have to believe the program is “worth it” – month in and month out. Consider how you will deliver and demonstrate value to your patients:

Will you have patient engagement and care management strategies designed to keep patients enrolled in the program?
Access to a patient portal may meet CMS guidance around enhanced communication, but patient retention depends on the value you can deliver. If your patient population does not utilize your portal consistently, they may unenroll from your APCM program. How can you reduce communication friction and make it easy for patients to engage?
Will you be able to systematically report on what you’ve done for patients each month? For example: what progress did you help the patient make on their care plan? How will you share that report with the patient?

WIth APCM, CMS is pushing you to think about the care management needs of your patient population as a whole.

“Analyze patient population data to identify gaps in care and offer additional interventions, as appropriate”
“Risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients”

– Medicare 2025 Physician Fee Schedule

Consider how you will achieve the population health management goals built into APCM:

How will you handle performance measurement and reporting requirements?
Are you prepared to analyze and understand the needs of your entire population? Do you have risk stratification capabilities? Will you be able to target services accordingly?
Risk stratification alone is not enough. How will you use that information to adjust the course of care appropriately for individual patients in real time?
Traditionally, care management is considered a scarce resource due to cost. Only a narrow slice of (high-risk, high-cost) patients get access to care manafgement. But If you can expand care management services across all your eligible patients, how will that enable you to drive early interventions for all the lower-risk patients at the bottom of your risk pyramid?

4. Billing

Smart billing ensures financial sustainability for your program. You may be familiar with time-based reimbursement for CCM. APCM reimbursement is different.

APCM reimbursement is not time-based, so you could bill for every consented patient, every month. Reimbursement depends on the number of chronic conditions and Qualified Medicare Beneficiary (QMB) status.

Code	Patient Population	% of Patients	Est. Monthly Reimbursement (Per Patient)	Est. Annual Reimbursement (Per Patient)
G0556	≤1 Chronic Condition	~20%	$15	$180
G0557	2+ Chronic Conditions	~70%	$50	$600
G0558	2+ Chronic Conditions & QMB Status	~10%	$110	$1,320

How will the program financials work for your particular organization and population?
If you are a multispecialty group or health system: How will you balance the needs of your primary care physicians versus your specialists, who might be better served by CCM programs?
Will APCM billing overwhelm your revenue cycle management team? Where can you leverage technology to streamline workflows?
Do you understand the related services that can and cannot be billed for a patient enrolled in APCM? (For example, you can bill for RPM and APCM, but you cannot bill for TCM and APCM.)
If you are in an ACO, have you thought about the value of using APCM enrollment to drive beneficiary enrollment versus the program counting against your Total Cost of Care?
In the future, how can you test Medicare Advantage reimbursement and optimize enrollment based on the results?

Traditional Medicare offers clarity through the Physician Fee Schedule. Medicare Advantage? Not so much.

5. Compliance

Compliance is not a “check-the-box” activity. It’s about doing the job right, every step of the way. A good APCM compliance strategy ensures that your program aligns regulatory requirements, operational workflows, and care management best practices.

How will you document care management activities in the EHR? Will it be completely manual? Are you relying on individual care managers to determine what is significant to your providers?
How will you document the specific care management activities that have been performed each month? CMS understands that not every care management activity will be conducted every month. However, you should be able to provide visibility into the high-quality primary care services that have been provided.
How will you ensure any time spent or activities performed will not be “double-counted” towards multiple care management programs?
In case of audit: do you have the systems necessary to be able to quickly produce all documentation for auditors demonstrating the compliant, high quality care management you’ve done?

Ideally, high-compliance APCM will ensure your program creates value for all stakeholders.

Need some help with your APCM plan?

There’s a lot to think about here.

Phamily is the market leader in high-quality, large-scale proactive care management. We’re happy to help you think through these questions – and many others – in more detail.

We can also provide a customized pro forma that synthesizes all the complex operational, clinical, and financial considerations your practice must evaluate.

Just reach out – we’re here to help.

Darshan Bachhawat

Chief Revenue Officer

Darshan has 15+ years experience co-founding and building high growth healthcare technology businesses committed to improving access to care and quality of care. More about Darshan…