Frequently Asked Questions for Staff

CCM is a Medicare program that allows providers and their clinical staff to earn

reimbursement for clinical activities performed between regularly scheduled visits.

Any Medicare or Medicare Advantage patient with two or more chronic conditions that has been seen by the billing practitioner within the past 12 months. Medicaid and Managed Medicaid patients are eligible for this program in certain states, assuming they meet the other requirements.

The Center for Medicare Services (CMS) defines chronic conditions as conditions

expected to last at least 12 months, or the patient’s death, that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline.

1. Create and share a personalized care plan with the patient (once)

2. 20+ minutes of non-face-to-face care (monthly)

Any between-visit interaction with the patient that helps them better manage their

overall health and chronic conditions. This includes patient education, chart reviews, lab reviews, prior authorizations, referral coordination, refilling medication, etc.

Team members operating under direct supervision of the billing practitioner on an

“incident to” basis. Clinical staff often includes MAs, NPs, and PAs, however, the billing practitioner is ultimately the one to determine who can perform what activity under their supervision.

1. Custom care plans to help patients manage their chronic conditions

2. Increased communication with providers and care team members to improve access to care. Access to care team without waiting in office!

3. Improved health outcomes due to increased access to care and the ability to

proactively address patient needs

4. Each patient gets a dedicated Care Manager

Patients with multiple chronic conditions often have barriers to accessing care and

improving their health. CCM allows providers to proactively surface these issues and other patient needs; improving quality of care and outcomes.

Most patients won’t pay a thing if they have supplemental insurance. However, standard Medicare cost-sharing applies to CCM just like it does for the patient’s medication and routine visits. It’s important to demonstrate the value of CCM to patients through ongoing outreach and support. If patients are concerned about copay, request that they try the program for one month to see the benefits. They can unenroll at any time.

Phamily is a HIPAA-compliant platform that allows your team to communicate with patients via text message. It is web-based, so it can be used from any device and does not require installation.

In addition to 1:1 patient communication, Phamily’s check-in feature allows your team to proactively engage hundreds of patients at once. Regular check-ins are proven to surface additional opportunities to address patient needs. Our AI helps select condition-driven, engaging messages so that patients continue to see the value in CCM. You can manage most things over text, eliminating the need for time-consuming phone conversations. The best part? Phamily records all communication to ensure top patient care, reimbursement, and efficient billing.

While it’s preferred that patients use text messaging to reach your office, it’s not

required. You can engage these patients with regular phone calls and log the time you spend with them in Phamily. Most of your CCM participants will engage via text, freeing up your time to manage patients who prefer a phone call.

Protected Health Information (PHI) is defined as any patient demographic information or health-related data like patient vitals, lab results, insurance information, and more. The Health Insurance Portability & Accountability Act (HIPAA) implemented various protections regarding the use and transmission of PHI, so it’s important to be mindful of whether a patient has provided PHI Authorization. You can collect written PHI Authorization in person or electronically using Phamily’s mobile-friendly forms.

If the patient has not provided PHI Authorization, it’s important that you do not send any demographic- or health-related information via text. Just call the patient instead or use Phamily’s PHI feature to send sensitive information behind an encrypted link.

Explain to the Patient that CCM is a Medicare program and is defined as Chronic Care Management. It's possible some commercial insurance providers are not familiar with the program, but most patients won’t pay a thing if they have supplemental insurance. However, standard Medicare cost-sharing applies to CCM just like it does for the patient’s medication and routine visits.