In-House Chronic Care Management's Hidden Costs

Why providers are contemplating DIY care coordination and how EHI's strategy overcomes systemic payment and compliance issues 

 Chronic Care Management (CCM) assists complex patients between visits, enhances outcomes, and stabilizes revenue. Many practices building and running CCM independently face operational, compliance, and financial challenges.

 Two Key Health System Articles Describe This:  

Medicare CCM payments were shown to be improper in a 2021 Office of Inspector General (OIG) report. There was double-billing, and the provided services were overlapping. Mistakes in billing led to beneficiaries overpaying (Medicare Continues To Make Overpayments for Chronic Care Management Services, Costing the Program and Its Beneficiaries Millions of Dollars, 2021).

The Patient-Centered Primary Care Payment framework describes fee-for-service payment models as ineffective in providing proactive chronic care and creating a disincentive for practices to be more efficient in the care of complex patients, as payment inadequacies will economically punish them. (Patient-Centered Payment for Primary Care, 2024)

These structural realities explain the countless failed in-house CCM attempts.

 Compliance Risks and Hidden Operational Costs 

Most CCM startups are unaware that operational compliance is a necessity.

• Strict federal billing standards, such as distinctive service periods and no overlapping codes

• Monitoring everything minute-by-minute

• Clear care plans and permission tracking 

The OIG reported that Medicare paid CCM as they received likely more reimbursements than allowed, as there were instances when claims didn’t meet the required federal definition. For example, CCM was billed twice under the same beneficiary, or CCM was billed for overlapped care management services. (Medicare Continues To Make Overpayments for Chronic Care Management Services, Costing the Program and Its Beneficiaries Millions of Dollars, 2021)

The Hidden Cost:  Risk of noncompliance includes unpaid/written-off accounts, claims denials, cost recovery, and client cost sharing.

EHI’s solution: In the following, we explain the integration of software and tools for the recommendation of advanced, real-compliance-oriented workflows.

 Internal Staffing Costs Mask True Expense 

In-house CCM is a full clinical service, requiring:

• Trained clinical teams

• Care planning and updates

• Time tracking that is Medicare compliant

• Contacting hard-to-reach patients 

Advocates for Patient-Centered Primary Care comment that CCM with fee-for-service reimbursement and CCM reimbursement for Chronic Care Management is a loss of reimbursement, even grossly exceeding the limitations of reimbursement for quality chronic care. (Miller & D., 2023)

The hidden cost:  Usually, the internal CCM Process relocates nurses and care coordinators away from the clinic to a focus that can be revenue-productive; this can, more concerning, limit overall continuity of care to patients

EHI’s approach: Without manual workload on clinical teams, we perform proactive outreach and chronic care documentation using AI tools and clinical expertise.

 Technology Costs and Workflow Fragmentation 

CCM techniques usually include: 

• Call monitoring tools

• EHR documentation templates

• Time-logging systems

• Analytics tools 

Fragmented stacks lead to inefficiencies and billable errors, from which audit reports show the OIG has generated millions from these fraud overpayments. 

The hidden cost: Integration issues, excess licenses, and staff training slow patient care.

EHI’s advantage:  Our combined CCM platform integrates your EHR and care coordination technologies to ease workflows and lower system burden.

 Engagement issues and revenue loss 

To profit from CCM, you need to contact people often and document everything properly. Practices lose on billing if patients do not answer their calls or if staff fail to document qualifying time correctly.

Based on the research on patient-centered payments, these factors often leave clinics understaffed and under-resourced despite having good patient care. Miller & D, 2023

The hidden cost:  Lost minutes, lack of engagement, poor billing.

EHI’s answer: Our service provides multilingual, nurse-led contact with artificial intelligence telephony to improve billing and complete CCM. 

 Engagement Challenges and Missed Revenue 

The fee-for-service system was not designed to finance proactive chronic care. We advocate the patient-centered primary care payment model, which states that:

• Fee-for-service often pays less than the true cost of chronic condition care.

• Current models punish success because healthier patients have fewer billable events. 

The hidden cost: Practices can provide good care to patients, yet they will not economically sustain their practice. Care for patients will outweigh the monetary compensation.

EHI’s process: Our CCM program offers a guaranteed equitable income distribution and CMS-compliant documentation and treatment, which seamlessly integrates into reimbursement frameworks. This will help the practice financially succeed.

 Enable Healthcare mitigates in-house CCM challenges by ensuring CMS-compliant billing with audit-proof documentation. AI-powered admin simplification, nurse-guided patient engagement enhancements, streamlined workflow integrations, and revenue maximization within the FFS CCM.

CCM offered by EHI utilizes Aria One’s Lumina AI Scribe and Echo AI Agent to support the financial viability of practices. This prevents the operational drag and compliance risks commonly faced by providers.