Chronic Care Management Program Overview

Transcription

1 Chronic Care Management Program Overview CPT Code

2 Table Of Contents I. Chronic Care Management Overview Population Health - Why Chronic Care Management...2 Population Health - Supporting Clinical Evidence...3 II. CPT Code Chronic Care Management (CCM) CCM CPT Code Overview And Billing Requirements...5 Provider Practice Revenue Potential...8 III. eqhealth Solutions Chronic Care Management Program Product Offerings And Descriptions...9 Operational Overview...11 Example Scenarios...12 IV. FAQs Frequently Asked Questions

3 I. Chronic Care Management Overview Population Health - Why Chronic Care Management According to the Center for Disease Control (CDC), about half of all adults 117 million people have one or more chronic health conditions. And one of four adults has two or more chronic health conditions 1. Seven of the top 10 causes of death in 2010 were chronic diseases. Two of these chronic diseases heart disease and cancer together accounted for nearly 48% of all deaths 2. And eighty-four percent of all health care spending in 2006 was for 50% of the population who have one or more chronic medical conditions 3. CMS recognized chronic care management (CCM) as one of the critical components of primary care that contributes to better health for individuals and reduced expenditure growth. To help cover the costs of chronic care management, CMS established CPT code Focusing on patients with two or more chronic conditions by providing CCM services can help improve their healthcare quality and reduce costs. CCM services aid with appointment scheduling and reminders, medication reconciliation, wellness checks, and much more. Through CPT code 99490, healthcare providers now have the opportunity to be reimbursed by CMS for providing such CCM services on qualifying Medicare patients. Beginning in January 2015, this CPT code allows reimbursement at an average of ~ $40 for chronic care management services performed on Medicare beneficiaries with two or more chronic conditions. A few of the requirements include 20 minutes of CCM services per month, 24/7 provider access, and beneficiary consent. Population Health - Where Is the Money Going? Exhibit 1 - The disproportion of how money is spent on insurance members from IMS Institute for Healthcare Informatics 1 Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11: Centers for Disease Control and Prevention. Death and Mortality. NCHS FastStats Web site. Accessed December 20, Robert Wood Johnson Foundation. Chronic Care: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation; Accessed December 23,

4 I. Chronic Care Management Overview Population Health - Supporting Clinical Evidence Over the past ten years, several studies have been published showing the benefits of various care management models. These studies illustrate better outcomes for patients, as well as a higher ROI. A few of these studies are illustrated below. 1) 3rd Party Literature Review Of Various Programs Exhibit 2 - A Comprehensive Literature Review of Studies on Care Coordination and Other Health Management Programs, performed on various care management programs and their outcomes 1. A 3rd Party review of care coordination yielded the best ROI from clinical and utilization outcomes, driven primarily from decreased hospitalization, ER and hospital days. Clinical outcomes and ROI were better with care coordination than any other form of intervention. Source: A Comprehensive Literature Review of Studies on Care Coordination and Other Health Management Programs, Shirley Musich, Ph.D. and Sadhna Paralkar, M.D., November 2007, Reden & Anders (now optuminsight) 3

5 I. Chronic Care Management Overview Population Health - Supporting Clinical Evidence (Cont.) 2) Health Affairs (2014) - Disease Management (DM) has greater ROI than Lifestyle Management in Workplace: 3.78:1 vs. 0.48:1 Jan, 2014: A new study found that disease management programs in the workplace lead to greater savings that lifestyle management. DM was offered to employees with at least one of the 10 chronic conditions and focused on improving medication adherence and patient self-care knowledge and abilities. The lifestyle management and disease management components were estimated to return on average of $0.48 and $3.78, respectively, for every dollar invested when both healthcare and absenteeism impacts were included. Exhibit 3 - Charts showing disease management vs. lifestyle management ROI outcomes Source: Managing Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven Years. John P. Caloyeras, Hangsheng Liu, Ellen Exum, Megan Broderick, and Soeren Mattke Health Affairs January : ) Carnegie Mellon (2007) - Study concluded 2:1 ROI from Blue Shield of California s comprehensive, community-based, patient-centered management This 18-month study of Blue Shield of California s case management program for HMO members diagnosed with late-stage illnesses showed a 2:1 return on investment. Reduced hospital admissions by 38 percent Reduced hospital days by 36 percent Reduced emergency room visits by 30 percent Overall cost reduction of 26 percent 2:1 ROI Source: Patient-centered Management of Complex Patients Can Reduce Costs Without Shortening Life. Latanya Sweeney, PhD; Andrew Halpert, MD; and Joan Waranoff, MBA - (Am J Manag Care. 2007;13:84-92) 4

6 II. CPT Code Chronic Care Management CCM CPT Code Overview And Billing Requirements Chronic care management, as required by CMS to bill for CPT code 99490, involves non-face-to-face services that must be performed by a physician or other qualified healthcare professionals to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services must be performed for at least 20 minutes once a month to each beneficiary. In additon to the required 20 minutes per month, several other requirements must be met. As illustrated in the roadmap below, CPT Code billing requirements can be categorized in three major steps: 1. Medicare beneficiary requirements, 2. technology requirements and 3. CCM services requirements. Medicare Beneficiary Requirements Technology Requirements Chronic Care Management Services 5

7 II. CPT Code Chronic Care Management CCM CPT Code Overview And Billing Requirements (Cont.) Below is a step-by-step description of requirements needed under the three major categories. Medicare beneficiary requirements Qualified Medicare Beneficiaries A patient who has been diagnosed with two or more chronic conditions expected to last for at least 12 months, or until death of the patient Obtaining Medicare Beneficiary Consent Provider must inform beneficiary of the following: CCM program description Manner in which CCM services will be provided The right to stop the CCM services at any time Only one practitioner can provide theses services during a calendar month Health information will be shared with other practitioners Beneficiary will be responsible for associated copays or deductibles Technology Requirements EHR Technology Requirements Must be certified - satisfying either the 2011 or 2014 edition of the certification criteria for the EHR Incentive Programs Include the following patient data: demographics, problems, medications, and medication allergies (consistent with 45 CFR (a)(3)-(7)) Allow for the creation of a structured clinical summary record (consistent with 45 CFR (e)(2)) Provider must be able to transmit the summary record for purposes of care coordination House the beneficiary consent of CCM services House the beneficiary receipt of care plan (electronic/hard copy) Document communication to and from home and community-based providers Electronic Care Plan Requirements (available 24/7) Allow provider to create an electronic care plan based on the physical, mental, psychosocial, cognitive, functional and environmental assessment of beneficiary Ability to update and share care plan with other practitioners and care members on a 24/7 basis Opportunities for beneficiary and any caregiver to communicate with the practitioner CCM Service Requirements Chronic Care Management Services Requirements Provide 20+ minutes of non-face-to-face care management services Beneficiary access to care management services 24/7 Continuity of care with a designated practitioner/care team member ability to get successive routine appointments Monitor beneficiary s condition - care management of chronic conditions Ensure beneficiary receipt of preventive care services Medication reconciliation Oversight of beneficiary self-management of medications Follow up after ER visits Help coordinate transition of care 6

8 II. CPT Code Chronic Care Management CCM CPT Code Overview And Billing Requirements (Cont.) The table below provides a summary overview of CMS billing requirements as well as an overview of eqhealth product and service solutions. CMS Billing Requirements Summary CCM Scope of Service Element/Billing Requirements* Provider EHR CCM Certified eqsuite CCM Software eqcare CCM Services Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care. Access to care management services 24/7 (providing the beneficiary with a means to make timely contact with health care providers in the practice to address his or her urgent chronic care needs regardless of the time of day or day of week). Continuity of care with a designated practitioner or member of the care team with who the beneficiary is able to get successive routine appointments. Care management for chronic conditions including systematic assessment of the beneficiary s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of beneficiary self-management of medications. Creation of a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues. Share the care plan as appropriate with other practitioners and providers. Provide the beneficiary with a written or electronic copy of the care plan document and document its provision in the electronic medical record. Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities. Coordination with home and community-based clinical service providers Enhanced opportunities for the beneficiary and any caregiver to communicate with the practitioner regarding the beneficiary s care through not only telephone access, but also through the use of secure messaging, internet or other asynchronous non face-to-face consultation methods. Beneficiary consent - inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information with other treating providers. Document in the beneficiary s medical record that all of the CCM services were explained and offered, and note the beneficiary s decision to accept or decline these services. Beneficiary consent - inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services. Beneficiary consent - inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month. Exhibit 4 - Requirements from physician office, technology and services Source: Page 67728:Federal Register/Vol. 79, No. 219/Thursday, November 13, 2014/Rules and Regulations 7

9 II. CPT Code Chronic Care Management Provider Practice Revenue Potential Based on national data, the table below calculates the revenue potential for a single provider billing for CPT code If a provider performs CCM services for their census of qualifying Medicare patients, their additional revenue potential is $251,000. The revenue potential only grows with the number of providers per physician group. The greater number of physicians, the higher revenue potential for the physician practice. Exhibit 5 - Potential Annual Gross Revenue Per Provider Potential Revenue Per Provider Description Average Annual Number of Unique Patients % Patients Covered by Medicare % Annual Number of Unique Medicare Patients 716 Medicare Patients w/ 2+ Chronic Conditions % Annual Number of Unique CCM Patients 491 CCM Monthly Payment 3 $42.60 Estimated Annual Gross Revenue for Family Medicine Physician $251,000 $25,000,000 Potential Revenue By Number Of Providers $20,000,000 $15,000,000 $10,000,000 Revenue $5,000,000 $ # Of Billing Providers For CCM Services Exhibit 6 - Growth of Revenue by Number of Providers 1 Per the MGMA Cost Survey for Single Specialty Practices: 2013 Report Based on 2012 Data specific to the specialty of family medicine. Includes Medicare A/B and Medicare Advantage. 2 CMS.gov County Level Multiple Chronic Conditions (MCC) Table: 2012 Prevalence, National Average 3 Reimbursement amount from the CY 2015 Physician Fee Service Final Rule; assumes 100% of unique patients are covered by Medicare A/B. Medicare Advantage reimbursement may vary. 8

10 III. eqhealth Solutions Chronic Care Management Program Product Offerings And Descriptions eqhealth Chronic Care Management (CCM) Program is designed to be a turnkey solution for provider practices and organizations seeking to take advantage of CPT code Our community-based nursing services (eqcare ) and robust care management technology (eqsuite ) offers a complete solution for executing and billing for CCM services. eqhealth Partnership Benefits: Immediate Revenue Realization 25+ Years Working With Medicare Populations Cloud-Based Care Management Software Billing Reports And Audit Trails Experienced Care Coordination Clinicians 24/7 Nursing Support Line Option Strong Internal IT Infrastructure Decades Executing Quality Improvement eqcare eqcare Chronic Care Management services support providers by administering CCM activities for Medicare patients with two or more chronic conditions. Our goal is to help improve the health of patients while growing practice revenue and profitability. eqcare Chronic Care Management services allow providers to oversee the program, while we take on the burden of hiring, staffing, and operating this program with experienced clinicians to give the best care to your patients. Our experience in providing the right nurses along with advanced care coordination software will give providers the confidence, value, time and stress reduction of not managing in-house. Key Features/Benefits: Embedded care coordinators provide care management to identified members for 20+ minutes a month Nurses are hired within the community and work closely with all care staff Experienced in complex case management/disease management/psychosocial assessments Monitor beneficiary s condition and update chronic care management activities as needed Perform ongoing medication adherence and reconciliation Ensure beneficiaries schedule preventative services Educate beneficiaries regarding their conditions Facilitate routine appointment scheduling and reminders 24/7 nurse line option URAC certified in disease management eqcare services and eqsuite technology help you meet ALL the requirements for Chronic Care Management CPT Code

11 III. eqhealth Solutions Chronic Care Management Program Product Offerings And Descriptions (Cont.) eqsuite eqsuite is a cloud-based, modular technology platform. It is tailored to meet all the electronic care plan requirements for CPT code The intuitive design helps providers, care teams and administrators leverage a sophisticated engine to identify and manage patients with 2+ chronic conditions. eqsuite technology is the ideal platform to create and manage care plans for these identified patients. It includes feature rich capabilities beyond typical electronic care plan software. Benefits/features of eqsuite software include: Chronic condition analytics and predictive modeling o Johns Hopkins ACG Model Engine o Patient Risk Stratification and Program Assignment 24/7 system accessibility to all care team members Comprehensive assessments o Whole person model o Condition specific assessments o Diabetes o Asthma o COPD o CHF o CKD o Hypertension o Oncology o Depression o Maternity o HIV o Stoke o Pediatrics o Complex case management o Behavior health o Medication adherence o Smoking cessation o Care transitions Individualized electronic plan of care (tracking issues, goals, and interventions) Integration with evidence-based guidelines Optimized care manager workflow engine o Daily work queue o Patient dashboards o Patient level claims history o Patient level comprehensive clinical profile o Clinical tracker (for biometrics data) o Session notes o Correspondence o Attachments o Drug alerts (Drug-Drug Interactions, Duplication, Drug-Food Interactions) o Provider channeling (to minimize network leakage) Secure messaging Health education materials o By condition o By medication Provider/patient portals Reporting capabilities o Population assessments o Biometrics reports o Billing reports (support for CPT code 99490)

12 III. eqhealth Solutions Chronic Care Management Program Operational Overview The graphic below outlines the basic steps taken to ensure billing for CCM Services. A detailed operational flowchart is available upon request. CCM Eligible Medicare Patients Identified Patients Opt-In To CCM Program Care Coordination Services Performed Reports Generated For Provider To Bill 01. eqhealth Solutions eqsuite technology software can be used to identify patients who fit into the eligible category to receive chronic care management. 02. Eligible patients are reached out to for the option to opt-in to the Chronic Care Management Program. 03. Chronic care management services are performed, which consists of 20 minutes of face-to-face or telephonic care coordination services each month per patient. 04. Audit reports are generated through eqhealth s software and delivered to your billing department to prompt billing for CPT Code

13 III. eqhealth Solutions Chronic Care Management Program Example Scenarios SCENARIO A: Physician Office With Limited Resources Problem: Dr. Jones has a family medicine practice that includes several hundred Medicare patients. His practice uses a certified EHR system and is interested in leveraging the new CCM code to help manage his Medicare patients with 2+ chronic conditions. Dr. Jones realizes his practice does not have enough time or personnel to perform the required 20 minutes of services a month or a 24/7 option to fulfill the billing requirements. In addition, his EHR system does not have a robust care management module. Dr. Jones believes the $40 a month reimbursement per beneficiary is not worth the technology investments or additional work needed to start billing for the code. Solution: eqhealth s Chronic Care Management (CCM) Program was designed specifically to support providers in both technology and nursing resources to perform CCM services and support CPT billing. The eqsuite technology platform provides Dr Jones a list of patients with 2+ chronic conditions, then serves as the electronic care plan platform for managing those patients. In addition, community-based nurses are brought in to support in CCM services execution. They help with obtaining consent, customizing a care plan, and performing 20 minutes of CCM services to each identified patient. A 24/7 nurse line option is also provided. The eqsuite technology tracks all interactions and reports the time for billing and auditing purposes. Results: Dr. Jones partners with eqhealth to leverage the CCM program technology and nursing resources. His practice receives an extra $20,000/month ($240,000 a year) of revenue while realizing 20% profit. Since no upfront investment was required, he is satisfied knowing his Medicare patients are getting extra care management and his practice is not overburdened with additional work. SCENARIO B: Physician Group With Large Medicare Population Problem: Dr. Smith oversees a 50 member physician group that includes several internal medicine and family practitioners. She is looking for options to start generating additional revenue within the next 90 days. They utilize a certified EHR system and already have a 24/7 nurse line in place. She likes the potential clinical and reimbursement benefits of CCM, but does not have the management budget or time to scale up and manage a CCM program in-house. Solution: eqhealth s Chronic Care Management (CCM) Program was designed specifically to be a turnkey solution both in technology and nursing support services. The upfront implementation time is efficient, allowing for new revenue generation within days. Implementation includes analyzing which Medicare patients qualify for the CCM program and hiring of community based nurses. The CCM program then provides the needed ongoing technology infrastructure and nursing services for CCM services. Monthly CCM services billing reports are generated and sent to Dr. Smith s office and billing department, allowing for immediate revenue growth. Results: Dr. Jones decides to leverage the eqhealth CCM program. Within 45 days, the qualified Medicare beneficiaries enrollment is ramping at rate of 150 new members a month. Dr. Jones is forecasting an additional $1 million of revenue to the group, while maintaining 20% profit margins. The patients and providers are satisfied with having a support nurse helping them proactively manage their conditions. 12

14 IV. FAQs Q: Is the CCM Program customizable? A: Yes, our offerings are customizable to your needs. We will fill in the gaps of care for any services you may be missing. Q: How do you identify patients eligible for CCM Program? A: Our eqsuite software system stratifies all of your patients and can identify Medicare beneficiaries with two or more chronic diseases. These patients can then receive chronic care management services. Q: How does eqhealth bill for their services? A: A report will be generated at the end of each month that will identify all patients who have received 20 or more minutes of chronic care management services. This report can then be used to bill for these services. Q: Can more than one physician bill for CCM services? A: No, only one physician can bill for CCM services per month. Q: What is the implementation timeline for your CCM Program? A: days. Q: What states does eqhealth serve? A: eqhealth has offices in numerous states and can perform services anywhere in the country. Q: Are Medicare beneficiaries who qualify for CCM services required to pay a copay? A: Yes, 20% coinsurance is required, but if the member has supplemental insurance or is a dual-eligible (Medicare and Medicaid), the copayment will likely be covered. 13

15 Contact us today for more information Corporate Headquarters: 8591 United Plaza Blvd., Ste. 270, Baton Rouge, Louisiana eqhealth Solutions, Inc. All rights reserved. All other trademarks designated herein are proprietary to eqhealth Solutions, its affiliates and/or licensors. DSL# (12/14)