Chronic Care Management

Chronic Care Management Solutions for Smarter Practice Growth

At RPM & CCM Health, we believe delivering high-quality care shouldn’t create more work for your practice. That’s why we’ve developed a comprehensive Chronic Care Management (CCM) program that boosts revenue, improves patient outcomes, and integrates seamlessly into your existing EHR—all with minimal disruption to your current workflow. Whether you’re managing a solo practice or a multi-speciality group, our fully integrated CCM solution empowers you to tap into scalable Medicare reimbursements that remain a key opportunity for providers nationwide.

With registered nurses, dietitians, and certified diabetes educators managing monthly check-ins, your practice can achieve a 91% patient retention rate, streamlined operations, and reliable monthly reimbursements. And it all starts with a free, no-obligation analysis.

What Is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a Medicare-approved service designed to support patients living with two or more chronic conditions. It involves non-face-to-face care coordination between office visits, with a focus on improving long-term health through personalised care plans, monthly check-ins, and proactive health monitoring. Eligible conditions typically include diabetes, hypertension, heart disease, and COPD—conditions expected to last at least 12 months or until the end of the patient’s life. Yet despite its benefits, about 40% of eligible patients are currently enrolled, leaving millions without consistent support and providers without access to a valuable reimbursement opportunity.

Why Most Practices Are Leaving Revenue on the Table

 A large portion of Medicare patients are eligible for chronic care coordination, yet adoption among providers remains relatively low. Only a small number of practices are fully utilising the available billing codes. This gap represents a major opportunity for growth, especially in light of recent increases in reimbursement rates. CPT code 99490 allows providers to bill for the first 20 minutes of non-face-to-face care coordination each month and provides a reliable reimbursement option. These changes reflect not only strong revenue potential but also increased federal support for remote care services. If your practice hasn’t adopted CCM yet, you may be missing out on improved outcomes and a steady stream of monthly revenue.

Based on current Medicare fee schedule estimates

What You & Your Patients Get With Our Full-Service CCM

When you partner with RPM & CCM Health, you’re not just signing up for a billing service—you’re gaining a fully managed care coordination team that supports both your practice and your patients. Our comprehensive services include:

• Appointment scheduling
  
• Medication reconciliation and refills
  
• Patient education on chronic conditions
  
• Custom care plans
  
• Monthly 20-minute check-ins
  
• Support groups (diabetes, weight loss, heart health)
  
• EHR data entry
  
• Nurse triage with escalation only for clinically actionable issues
  
• Care team microsites
  
• Ongoing patient engagement campaigns

Launch in as Little as 48 Hours

Our onboarding process is fast, straightforward, and designed to get your program up and running within 48 hours. It starts with a quick review of your most common billing data—no sensitive patient information required. From there, we walk you through our care model, introduce your dedicated support team, and demonstrate how we integrate directly with your EHR. There’s no learning curve for your staff, no added workload, and no long-term contract. Every rollout is tailored to your practice’s needs and patient demographics to ensure maximum impact from day one.

What Sets Us Apart From Other CCM Vendors

What truly sets RPM & CCM Health apart is the strength of our team and the flexibility of our platform. We work with certified nurses, licensed dietitians, and credentialed diabetes educators who not only meet clinical standards but also build lasting trust with your patients.

• Certified Nurses, RDs, and Diabetes Educators
  
• 91% patient retention after 12 months
  
• Patient education programs & webinars
• High-touch care coordination without placing extra demands on your staff
• Branded care materials that reflect your practice’s identity and voice

How CCM and RPM Work Together

While these services complement each other, they serve distinct purposes. CCM focuses on care coordination through monthly planning and patient outreach, while RPM centres around the use of connected devices like blood pressure monitors and glucose meters. Our platform supports both, giving you the flexibility to build a care model tailored to a wide range of patient needs. If you’re looking to expand your services, visit our RPM page to see how these programs can work together seamlessly.

What Our Partner Practices Say

“At first, we were unsure whether to outsource CCM services, but RPM & CCM Health made the process seamless. Within three months, we started seeing better results, our team felt the support, not replaced, and the patient stayed healthier between every visit.” — Dr. Karen Liu, Internal Medicine, Houston, TX.

Since partnering with RPM & CCM Health, our practice has added over $18,000 in recurring monthly revenue without hiring a single additional staff member. Their nurses have become an extension of our team, and patient feedback has been overwhelmingly positive.”
– James M., Practice Manager, Primary Care Group, New Jersey

CCM FAQs for Providers

What qualifies a patient for Chronic Care Management (CCM)?

A patient must have two or more chronic conditions that are expected to last at least 12 months or until the end of life.

Will my EHR system work with your platform?

Yes, our CCM program for medical practice integrates seamlessly with all major EHR systems and can be up and running in as little as 48 hours. We streamline data sharing, documentation, and CCM billing to ensure your workflow stays efficient and uninterrupted.

Do I need to hire additional staff to implement CCM?

Not at all, our turnkey solution dissolves the need for new hiring. We serve as an extension of your care team, handling everything from follow-ups to patient education. 

Start Your CCM Program Today

With RPM & CCM Health, implementation is quick, integration is seamless, and the results speak for themselves. A 15-minute discovery call could help you recover thousands in missed reimbursements—without hiring additional staff. Call us today at 914-420-1023 to schedule your free analysis!