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Starting your CCM Program with Accuhealth

This article describes the details of Accuhealth's CCM program and how to immediately get started

Who is Eligible to Receive CCM Services from Accuhealth

Chronic Care Management (CCM) is a Medicare Part B service; however, many commercial (non-medicare) insurances also cover CCM services. For a patient to be eligible, they must have two or more chronic conditions that are likely to remain with the patients for the remainder of their active life.  The spirit of CCM services is to provide a dedicated concierge clinical coordinator from Accuhealth that will assist the patient in best managing their chronic conditions to live their best life possible.

Accuhealth Client Success will Qualify your patient census

As a starting point - your accuhealth Client Success Representative will review your existing patient census receiving RPM services with Accuhealth, as well as run a report on eligible patients not currently receiving RPM services with Accuhealth, and return the list of eligible patients that can be referred for CCM.  

Tip - We recommend starting with your Active patients Receiving RPM services as its a perfect complementary service and all these patients qualify for CCM services.  

Engaging your Patients for Acceptance and Ongoing CCM Services

The following engagement process outlines how Accuhealth will engage your patients for CCM Services:

  1. Patient Acceptance and Informed Consent - Using an engagement process, which includes personalized mail, text, and phone calls from their Accuhealth CCM Clinical Nurse, the program is explained and a verbal consent is obtained from the patient. (See Appendix I - Patient Acceptance Script).  Patient Consent is stored in the Evelyn CCM software and can be downloaded anytime with a click of a button.
  2. Patient Onboarding - The Accuhealth CCM Clinical Nurse onboards the patient using the award-winning Evelyn software which includes a documented process of Health Plan Questionnaires, Documented Medical and Physical History, Documented Conditions, Documented Medications, Documented Health and Self-Directed Goals, resulting in a finalized CCM Care Plan for the patient.
  3. Concierge Clinical Coordination - The Accuhealth CCM Clinical Nurse will provide ongoing and dedicated concierge clinical coordination for all aspects of the patients healthcare.
  4. Documentation and Reporting - All documentation, including Phone Calls, SMS, Clinical Notes, are stored in the Evelyn CCM platform, and a CCM Patient Summary report will automatically be uploaded to the patient's EMR chart at the end of each month.  The Evelyn CCM software automatically tracks and audits all interactions resulting in an audit monthly billing report.
  5. Billing - Your clinic will receive a monthly billing report that will be turn-key. For all our Athena clinics, your CCM claims will be automatically dropped for you.

The Value of CCM for your Patients 

Through Accuhealth's chronic care management program, we coordinate all patient health care so that the patient can be as healthy as possible. This includes coordination of the health care the patient gets from the your clinic, as well as the care the patient may get at another doctor’s office, at the hospital, at the pharmacy, at the home, or from a community service organization. Here are some of the other benefits patient's will get from chronic care management:

• A member of Accuhealth's care team will be accessible to you 24 hours a day, 7 days a week to address your urgent care needs so

that you can get this care regardless of the time of day or day of the week.

• Accuhealth will schedule any preventive care that you need; for example, we’ll be sure that you get the flu vaccine at the right time every year.

• The Patient will always be able to schedule routine appointments with a designated member of your care team.

• Accuhealth will closely monitor your medicines.

• Accuhealth will coordinate with home- and community-based providers regarding your care.

• Accuhealth will work with you to create a personalized care plan and to update it as necessary.

The Value of CCM for your Clinic

Your clinic will benefit in the following ways (Just like you do using Accuhealth's RPM Services)

  • Alleviates the constraint of resources to keep up with the growing demand of services from your chronic patient, by referring all your chronic Medicare beneficiaries to Accuhealth for CCM services.
  • Improved patient outcomes and value-based scores while reducing cognitive overload of your clinics Doctors and Providers.
  • Improved Medication Adherence for your patients
  • Improved Patient Loyalty
  • Improved Financial Viability for your clinic

The Unit Economics of CCM

There are two CPT codes available to provide CCM services incident to and under the general supervision of your clinic.

CPT Code Description Reimbursement Accuhealth Fee
99490 non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability $64.02 $25
99439 Addon code for additional units of 20-min of interactive time, capped at two (2) additional units. $48.45 $20 per unit

Using CPT Codes 99490 - first 20min of monthly interactive time, and 99439 - add-on code for up to two additional units of 20min of interactive time, 99490 reimburses $64.02 and we invoice $25, 99439 reimburses $48.45 per unit - we invoice $20 per unit up to a max of 2 units.

As an example, 100 patients on CCM nets your clinic $9500/month after paying the Accuhealth Fees - this is an average and most localities reimburse higher.


Appendix I - Patient Acceptance Script

For consistency and quality, our CCM patient Acceptance staffs follows a structured and natural sounding script that maximizes patient acceptance and maintains compliance with CMS.


Hi this is <CCM Resource Name> calling on behalf of Dr. ******. May I speak to <Patient Name>

Hi  <Patient Name>, this is <CCM Resource Name> calling on behalf of Dr. ******, how are you?! (Wait) Good! So I do have to quickly let you know that I’m calling on a recorded line and the reason I’m reaching out is because Dr. ***** asked that I briefly tell you about our new service he/she’d like you to participate in. 

As I mentioned, my name is <CCM Resource Name> and I’m with Accuhealth, a company that Dr. ****** hired to improve your care by assigning you one of our personal care managers who would be working with you each month to help you with things like…

  • Scheduling your doctors appointments 
  • Monitoring your medications 
  • Creating a personalized care plan to make sure you’re reaching your health goals
  • And being available to you 24 hours a day / 7 days a week for anything you need at all. Basically <patient name> look at us as a concierge service to help you with anything you need when it comes to your health

And <patient name> in case you’re curious, the reason why Dr. **** feels this is a great service for you is because of the <1st chronic condition> and <2nd chronic condition> conditions that you have. Because of that, we just want to make sure we’re doing everything we can to keep these conditions controlled, and keep you healthy long-term.

That said, we reviewed your insurance, and because you have Medicare, it will cover the cost, but if you don’t have supplemental insurance there might be a small copay. BUT, if that’s the case <patient name> it might cost you only $8 a month. But if you were to hire us without insurance (and many patients do) our service would cost over $1,000 a month because of how much we’re doing for our patients. And <patient name> if you do end up having a co-pay and aren’t seeing the value you can literally cancel at any time. 

That said, I personally chose your care manager, his/her name is <care manager name>. He/she is GREAT. You will love working with them. They’ll be in contact with you on a monthly basis, by Phone and even text with you if you’d like, to coordinate the healthcare you receive from not only Dr. *****, but also any care you receive from any other doctor’s office, your local hospital, your pharmacy, or care you might receive at the home or anybody else. 

So <patient name> I just need to verify a few pieces of information to move forward. 

Dr. **** has your Address as…… . Is that still accurate?

And is your main phone number still ….. ? Is that your mobile number? (If yes) Okay, great. Are you okay with us texting you?

Ok great. So <Patient Name> Can Dr. ***** and I count on you to try this out?

If yes

Awesome, you’re all set. <Patient name>, if you don’t mind, I’d like to get you onboarded right now, it takes about 15 minutes. Do you have a little more time? Otherwise, we can schedule this for another time later today or tomorrow if that’s more convenient? I just have some questions to go over to get <care manager> fully up to speed.