Patient Review
CCP helps review which Medicare patients may qualify for CCM based on chronic conditions and program fit. This gives the practice a clearer starting point before outreach or enrollment begins.
How it works
How CCM Works For Your Practice
Chronic Care Management is monthly, non-face-to-face support for eligible Medicare patients with multiple chronic conditions. In practice, it means care-plan follow-up, patient outreach, coordination, medication-related support, and documentation between visits.
CCM, RPM, and MTM overview
- CCM
CCM - Core Monthly Support
Chronic Care Management gives eligible Medicare patients structured support between office visits. It includes monthly outreach, care-plan follow-up, coordination, medication-related support, and documentation tied back to the practice.
- RPM
RPM - Monitoring When Needed
Remote Patient Monitoring can add connected-device support for patients who need closer tracking, such as blood pressure, weight, glucose, or oxygen readings. It gives the care team more visibility between appointments when appropriate.
- MTM
MTM - Medication Review Support
Medication Therapy Management adds pharmacist-led review for patients with medication complexity. It can help identify concerns, support adherence, and give the practice another layer of medication-focused support.
FROM SETUP TO MONTHLY CARE
How We Help Your Practice Run CCM
The process starts with identifying Medicare patients who may qualify for CCM. From there, CCP helps with consent, enrollment, patient outreach, care coordination, medication-related follow-up, and documentation so the program can run under your practice’s oversight.
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Step 1
We identify likely eligible patients
CCP helps your practice find Medicare patients with two or more chronic conditions who may qualify for a managed CCM program.
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Step 2
We enroll patients and document consent
Patients receive a clear explanation of the service, the support involved, and any expected cost sharing before the monthly work begins. Consent is documented before the program starts.
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Step 3
We deliver the monthly care-management work
CCP's clinical team handles recurring outreach, care coordination, monitoring support, medication-related follow-up, and documentation through the month. The broader model includes access to an on-staff pharmacist.
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Step 4
Your practice stays in control and bills
Your providers remain the billing provider of record and retain clinical judgment. CCP supports the documentation and billing workflow so the service can run under your oversight.
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Step 5
Your practice receives monthly financial benefits
Finally, your practice receives monthly financial benefits as a result of the care-management service we provide to your patients.
CCM IMPLEMENTATION
Add CCM Without Building The System Yourself
CCP helps your practice move from identifying eligible Medicare patients to documenting consent, delivering monthly care-management support, and organizing the records behind the work. The goal is to make CCM operational without requiring your office to build the full process internally.
Consent & Enrollment
Patients receive a clear explanation of the service, the type of support involved, and any expected cost-sharing. Consent is documented before monthly care-management work begins.
Monthly Outreach
CCP supports recurring patient contact between visits so chronic patients are not only reached when they have an appointment. This includes follow-up around care plans, questions, and ongoing needs.
Care Coordination
The monthly work can include care-plan follow-up, medication-related support, monitoring coordination when applicable, and communication that helps keep patients connected to the practice.
Documentation & Oversight
CCP helps organize time tracking, care-management activity, and supporting documentation while your providers remain involved in the patient relationship and clinical direction.
The gap is between visits
Most chronic patients do not need more brochures. They need steady contact between appointments. They need reminders, coordination, medication follow-up, and a clear path to ask for help before a problem grows.
That monthly work is what care-management programs are meant to cover. It is useful for patients. It is also work that many small practices do not have the staff time to run consistently on their own.
Compliance should be built in from the start
Care-management programs should not be sold as easy money. They are regulated services with real documentation and consent rules. If the records are weak, the program is weak.
CCP's role is to help the practice run the service with documented consent, organized time tracking, archived records, and HIPAA-aware handling of patient information. CCP supports the process. CCP does not replace the provider's clinical judgment, and this page is not medical, legal, or financial advice.
What patients should be told clearly
Patients should know what the service is. They should know who is contacting them. They should know they can opt out. They should know there may be coinsurance. The conversation should be clear, not slippery.
That matters for trust. It also matters for enrollment quality. A patient who understands the program is more likely to stay engaged than a patient who was rushed through it.
Talk to an expert
If you want to see how this would work with your patient panel and your workflow, the next step is a short conversation. We can walk through eligibility, the monthly process, patient communication, documentation, and where RPM or pharmacist support may fit.
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