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“Compliance is a key foundation for any successful Chronic Care Management program,” explains Amanda Crouch, CPC, CPMA, CIC, CRC. Crouch is the VP of Operations at The Grant Group, a leader in healthcare revenue cycle management (RCM).
“Chronic Care Management compliance ensures we meet Medicare’s requirements,” Crouch continues. “These requirements include proper documentation, patient consent, and time-tracking for billable services. If you are non-compliant, payers can deny your claims. This will impact the financial health of your CCM program.”
After years of reviewing CCM programs, Crouch suggests practice leaders build a CCM compliance strategy for four reasons:
Medicare has strict requirements for CCM programs, including proper documentation, time tracking, and patient consent. If you are planning to bill for CCM services, you need appropriate controls in place.
Invest in these controls before you start delivering care management services to patients with chronic conditions. Waiting to think about compliance until after you have started CCM billing creates unnecessary risk for your practice.
Non-compliance can result in denied claims, financial penalties, or program exclusion.
“Audit readiness is another critical area,” warns Crouch. “By maintaining accurate records and following guidelines, we protect the CCM program from penalties and ensure it operates smoothly.”
Crouch recommends practices think about audit readiness before they begin CCM billing. Payers will conduct regular audits to ensure your practice is adhering to CCM standards. Your billing team should be able to provide any required documentation quickly and easily.
A well-documented and compliant CCM program minimizes the risk of financial penalties and reputational damage for the practice.
Fraud allegations and legal exposure can be devastating for an independent practice and painful for a health system.
You may recall that in late December 2024, news of a False Claims Act settlement roiled the cardiology world. The United States Department of Justice opened an investigation into overbilling on diagnostic drugs.
Ultimately, sixteen cardiology practices agreed to pay a total of $17.7M. That monetary payment may settle the charges. However, the reputational damage is hard to calculate.
Risk mitigation is an especially important consideration for practices considering an outsourced approach to care management services. Crouch reports seeing horror stories like months of CCM billing for deceased patients, or care plans that are the same across all patients.
A strong compliance strategy will ensure your practice follows ethical billing practices and accurate reporting. This minimizes the financial and reputational risk for your physicians or other qualified providers.
“A compliant program builds trust with patients, payers, and regulators,” says Crouch.
Building trust with patients is particularly important. At Phamily, we believe your most valuable asset is your trusted relationships with your patients. A strong CCM program can strengthen those bonds with continuous engagement.
But that means a care manager cannot just make a scripted phone call for 20 minutes one time each month. You need frequent communication, personalized care coordination, and a living comprehensive care plan aligned with the patient’s own goals.
Consistent engagement builds trust between your patient and their care manager. This means the patient feels comfortable escalating issues for early intervention. It also means that the patient sees value from your CCM program.
Ensuring patients see value is critical to program retention. Many of your patients have cost-sharing. For patients to continue to participate, they need to believe that your CCM program will help them.
The right compliance strategy will align program requirements with care management best practices. This helps you enroll and retain patients to ensure CCM provides a reliable revenue stream.
A strategic CCM compliance strategy (one designed to enhance patient retention) offers tremendous value to your practice. Ideally, you are building scalable care models that align practice operations with program requirements.
“Make sure that you think about how to scale high-quality care as you expand your program,” urges Crouch. “Think about how to foster workflows and collaboration across interdisciplinary teams. And make sure to build continuous staff training into your plans.”
For more information on best practices for CCM compliance, we encourage you to view our on-demand webinar.
WEBINAR
Whether you’re exploring CCM for the first time or looking to refine your current program, this webinar offers practical guidance on compliance.
Alyssa believes that solving between-visit care is critical to effective population health management and long-term success under value-based models. For over a decade, she has worked with innovative health systems, large medical groups, and payers across the United States to help them implement programs and share their successes under advanced payment models.
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