The Perfect Partner For Chronic Care Management

Healthcare systems today observe a boom in technology with a pressing need for personalized and effective patient care.

In the US, 6 in 10 have a chronic disease while 4 in 10 suffer from two or more chronic diseases. Humhealth’s Chronic Care Management platform paves the way to confusion-free care for patients with a bespoke care plan.

Chronic Care Management

Defining Chronic Care Management (CCM)

In 2015, Medicare and Medicaid Services in the United States made Chronic Care Management a vital part of connected care initiatives to improve patient’s quality of life.

About 85 percent of healthcare expenditures in the US go to chronic illness treatment. The CCM program was launched to curb costs on expensive emergency care and hospitalization. When CCM is administered the right way, 30 percent of unnecessary hospital visits can be cut, saving about $8.3 billion. CCM focuses on reducing hospitalization and scaling care at the comfort of home.

CCM – Care Beyond The Healthcare Setting

Enhances patient’s focus on their general wellness and health

CCM - Care Beyond The Healthcare Setting

Patients are aware that they are in safe hands, even outside the practice walls.

CCM - Care Beyond The Healthcare Setting

Ensures patient compliance with the practitioner recommendations

CCM - Care Beyond The Healthcare Setting

Web App Features

  • Personalized care plan for each patient

    Personalized care plan for each patient

  • Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing

    Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing

  • Two way communication with patient through Text Message

    Two way communication with patient through Text Message

  • Continuity of Care Document Upload and EMR Integration

    Continuity of Care Document Upload and EMR Integration

  • Feature to initiate video Call

    Feature to initiate Video Call

  • VOIP Integration with multiple vendors

    VOIP Integration with multiple vendors

  • HIPAA compliant Fax integration

    HIPAA compliant Fax integration

  • Synchronization of patient self-assessment data from Mobile app

    Synchronization of patient self-assessment data from Mobile app

  • Automated Time Tracker

    Automated Time Tracker

  • Define Care Team Members

    Define Care Team Members

  • Comprehensive Monthly Service Summary

    Comprehensive Monthly Service Summary

  • Comprehensive Scheduling Feature

    Comprehensive Scheduling Feature

  • CCM Current Month Status Dashboard

    CCM Current Month Status Dashboard

  • Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications

    Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications

  • Disease-specific questionnaire for common chronic diseases

    Disease-specific questionnaire for common chronic diseases

  • Questionnaire Configuration at facility and patient levels

    Questionnaire Configuration at facility and patient levels

Mobile App Features

  • Patient and Physician mobile app

    Patient and Physician mobile app

  • 24/7 access to care plan by patient

    24/7 access to care plan by patient

  • OTC Medication

    OTC Medication

  • Physical activity tracking

    Physical activity tracking

  • Record symptoms

    Record symptoms

Humhealth Mobile app
  • View the training session recording

    View the training session recording

  • View newsletter and educational material

    View newsletter and educational material

  • Calorie tracker

    Calorie tracker

  • Feature to attend a Video call

    Feature to attend a Video call

  • View call summary

    View call summary

How Does Our Chronic Care Management System Work?

Chronic Care Management Solution from Humhealth offers a comprehensive approach to manage wellbeing programs based on the latest guidelines, automated tech, and optimum care. We bring together technology and coordination strategies for the proactive care of at-risk patients. We extend our support to complex CCM, non-complex CCM, Rural Health Clinic, and Federally Qualified Health Centres.

Trained CCM navigators (Clinical Support Specialists) are on wheels with our technology and will be an extension of the clinician’s internal team to onboard and manage patients. Our platform helps to keep patients engaged and proactive throughout their treatment, starting from routine check-in to call assistance. The navigators corroborate that the patients are connected to resources, and their critical needs are met via our multi-faceted interface.

Our primary goal is to prevent care gaps and control costs. Chronic Care Management platform helps navigators to coordinate precisely with healthcare providers by consistently analyzing files for changes, making enhancements in the care setting.

CCM Workflow

  • workflow 1

    1

    Identify Eligible Chronic Patients

    Clinicians identify eligible patients with chronic diseases using his/her patient list or from Electronic Medical Records (EMR).
  • workflow 2

    2

    Enrol The Patient

    On identifying the patients with two or more chronic conditions, the clinicians will enrol the eligible patients for Chronic Care Management program following the patient’s consent.
  • workflow 3

    3

    Define A Care Plan

    Based on the patient’s health records, the Clinicians will formulate a suitable care plan. When a Clinician defines a care plan for a Patient, the automated timer will run to capture the time spent on providing CCM service and thus helps to keep track of chronic care records.
  • workflow 4

    4

    Monthly CCM

    The Clinician will have a monthly follow up call with the Patient to provide CCM service.
  • workflow 5

    5

    Track Time

    During the non-face-to-face interaction by a Clinician with the Patient, the automated timer will run to record the time spent on calling a patient.
  • workflow 6

    6

    Timely Reimbursement

    Most would accept that the tedious part of CCM is getting a reimbursement. Humhealth’s CCM platform tracks and records everything from calls and interactions, bills and generates simple billing reports. Then, all you have to do is to review and forward the reports to the biller.

Benefits Of Chronic Care Management

When executed accurately, Chronic Care Management is a win-win. The patients enjoy a better life through dedicated care and, the providers get access to infrastructure powered by reimbursements.

New Revenue Stream

On average, CCM generates above $500 revenue a year including, direct reimbursement for every active patient. It is alluring that CCM strengthens the pockets of healthcare practitioners. In addition to reimbursements, office visit revenues and ancillary service throughout the year bring in satisfying revenue.

Benefits Of Chronic Care Management

Orchestrated Care

Lack of care coordination often puts the patient in a pickle when they are dealing with multiple issues. Chronic Care Management acts as the ideal solution by offering organized care details for different conditions on a single platform.

Benefits Of Chronic Care Management

Why Make Humhealth Your Chronic Care Partner?

We commit to offer top-notch, cost-effective, and patient-centred Chronic Care Management applications.

Why Make Humhealth Your Chronic Care Partner
  • Optimized billing and payment strategies
  • Well-established connection with a patient via texts
  • Cost-effective resources
  • Orchestrated patient care
  • Tailored patient care plan
  • VOIP integration with multiple vendors

Healthcare providers and payers are eyeing remote care solutions and accelerate their journey to value-based care. Humhealth, with dynamic strategies and on-par technology, helps you achieve the results you need.

Billing Codes

  • CPT 99490

  • Chronic care management services provided by clinical staff and directed by a physician or other qualified health care professional (Non- Complex)
  • Duration 20 minutes
  • $42.84

    Average Reimbursement
  • CPT 99439

  • Add-on code – first increment (non-complex CCM)
  • Duration 20 minutes
  • $38

    Average Reimbursement
  • CPT 99439

  • Add-on code – second increment (non-complex CCM)
  • Duration 20 minutes
  • $38

    Average Reimbursement
  • CPT 99491

  • Chronic care management services, provided personally by a physician or other qualified health care professional
  • Duration 30 minutes
  • $84

    Average Reimbursement
  • CPT 99487

  • Complex Chronic care management services provided by clinical staff and directed by a physician or other qualified health care professional
  • Duration 60 minutes
  • $94.68

    Average Reimbursement
  • CPT 99489

  • Add-on code for Complex CCM Service
  • Duration 30 minutes
  • $47.16

    Average Reimbursement
  • CPT G0511

  • CCM Service for Rural Health Clinic (or) Federally Qualified Health Center
  • Duration 20 minutes
  • $67.03

    Average Reimbursement

FAQ

Medicare patients with at least two or more chronic diseases that are expected to be present for at least 12 months or until death of the patient.

Advance consent for CCM services may be verbal or written. If the consent is verbal, there should be documentation in the electronic health record reflecting this.

There are a wide range of services that can be provided under CCM for Medicare beneficiaries with multiple chronic conditions.
  • Care management and transitional care management services
  • Communicating with the Medicare beneficiary in person, by phone, or electronically for care coordination
  • Community resource referral and linkage
  • Coordinating community and social support service
  • Medication management
  • Symptom management
  • Preventive health counselling
  • Health coaching

Regular CCM covers 20 minutes of clinical staff time per month for ongoing oversight, management, and care planning.Complex CCM places the patient at significant risk of death. Minimum of 60 minutes of Clinical staff time is required with substantial revision of care planning and moderate to high complexity in medical decision making. All CCM services (regular and complex) must be provided under the supervision of a physician or non-physician provider (nurse practitioner or physician assistant).

The care plan should include the details of the following elements:
  • Problem list detailing the chronic conditions the patient suffers from
  • Expected outcome and the likely course of the disease
  • Measurable treatment goals
  • Symptom management
  • Planned interventions through regular follow-ups and vital data collection from patient
  • Medication management depending on any concerns/reactions/improvement reported by the patient
  • Care coordination plan between care provider and patient’s caregiver such as family/nurse/community housing etc.
  • Requirements for periodic review and revision of the care plan is required.

Yes. CMS requires the care provider to share the care plan with the patient in a written or electronic format.

CMS has stated the transmission has to be electronic. Facsimile transmission does not satisfy the requirement.

During any given month, a Medicare beneficiary can receive CCM or complex CCM, but NOT both. Only one qualified provider entity can bill for CCM services each month.

The CCM service period is one calendar month. Practitioners may report CCM at the conclusion of the service period, or after completion of the minimum required service time.

Chronic care management services can be billed if the beneficiary dies during the service period, as long as at least 20 minutes of qualifying services were furnished during that calendar month and all other billing requirements are met.

Physicians and Non-Physicians can claim reimbursement by billing for CCM CPT Codes. CCM code is most likely to be billed by primary care physicians. However, specialists, nurse practitioners, physician assistants, clinical nurse can also bill CCM.