In January 2015, choosing a turn-key CCM solution provider was relatively easy for a simple reason – there were very few companies offering such programs. Practices basically had only 2-3 options to consider. Today the landscape is different. Dramatically different. There are new CCM companies springing up every few weeks and today CCM companies are everywhere. By my count, there are at least 50 different companies providing some form of CCM services, and that number will continue to grow throughout 2016 because of the sheer size of the market.
With so many companies offering programs, does it really matter which company your practice partners with for a turn-key solution to your CCM needs? All companies are pretty much offering the same thing aren’t they?
I know, I know…you can get CCM with AUV from this company, and CCM with TCM from that company, and the super deluxe AUV/CCM/TCM package with free billing on top from yet another company, but the heart of every program – the turn-key CCM service portion everybody offers – isn’t it is really the same from every solution provider? Don’t they all have to meet the criteria set by CMS to be allowed to offer CCM services, and because of that, aren’t they “all just the same?”
Actually, “NO…they are not all just the same.” And just because a solution provider offers CCM services, it does not mean that their services actually meet with CMS criteria for compliant billing purposes. For the most part, CCM service providers do not take on the financial risk and penalties associated with non-compliant billing. That risk remains with the owner of the NPI associated with billing CMS. As an industry we probably really won’t know which programs are compliant until later this year or into 2017 after CMS has had time to conduct audits. Once that process starts and CMS begins clawing back money from physicians, and practices are forced to sue the non-compliant CCM providers, we will undoubtedly see some of the existing CCM companies exiting the market because their services were not compliant. Practices and physicians who partnered with those companies will be hurt.
“So how do we separate the compliant companies from the non-compliant companies?”
I’m not certain that there is a fool proof way, but my recommendation is that you ask the CCM provider you are considering questions – lots of questions. And ask the right questions. Questions such as the following:
- Do you guaranty in writing that your program is compliant with CMS guidelines, and do you indemnify our practice against losses associated with non-compliant services being billed to CMS and/or other payers? If the CCM provider is unwilling to contractually indemnify you against loss in the event the service they provide is deemed non-compliant, I would consider an alternate provider.
- For each patient enrolled, do you obtain all health records from all providers associated with the patient’s medical care? If the answer is “Yes,” the company is using best practice methods and I would consider working with that company. If the answer is “No,” the following question should be asked.
- How does your program meet the CCM scope of service element requiring “…an electronic care plan addressing all health issues…” to be created if you do not actively solicit and obtain all medical records from all providers associated with the enrolled patient? Although CMS has not specified that all health records need to be considered in forming the electronic care plan, they have stated that the plan must address “all health issues.” I am uncertain how CCM providers who do not solicit and obtain all health records associated with an enrolled patient are able to address “all health issues” as is required to compliantly bill. Ask them to describe the process they use to identify and address “all health issues” of the patients they enroll. There might be effective and acceptable methods other than the patient’s health records, but I am a fan of using the patient’s medical records. If they cannot describe their method of addressing“all health issues,” consider an alternate provider.
The following are additional questions that I would ask any potential CCM solution provider:
- How can a doctor outside my practice or health system that has a certified EHR electronically access the care plan?
- How can a doctor without a certified EHR electronically access the care plan?
- Can I enroll Medicare patients that do not have a computer or smartphone?
- Can patients in your model be compliantly billed even if they do not spend at least 20 minutes on the phone each month?
- Will you schedule appointments with any provider for my patient?
- Do you do on-site implementation of customized workflows?
- How does your solution help me transition to value based care?