Technology and reimbursement changes can mean major new revenue for providers

Providers have long known that patients’ behaviors in between visits have a huge effect on their health, especially for those with chronic conditions.

The fee-for-service medical payment model largely ignored this fact for a long time, however, so providers were unable to receive reimbursements from public or private payers for helping patients monitor and manage their health. Even practices that really wanted to provide effective, ongoing patient monitoring and care management could not fund such interventions given the many demands of today’s healthcare environment.

This is about to change in a big way, thanks to new technology plus long-overdue new reimbursement codes. Medicare has published reimbursement codes that could allow even small practices to earn hundreds of thousands of dollars a year for providing new forms of non-face-to-face care that can dramatically improve their patients’ lives.

New Reimbursement Codes
The last few years have seen a breakthrough in Medicare’s willingness to reimburse providers for non-face-to-face care, particularly for patients with severe chronic conditions. (Congress might have helped, when it passed the 21st Century Cures Act of 2016, by directing CMS to accelerate its study and adoption of preventive approaches in general, and of telehealth services specifically.)

There are two new reimbursement codes that offer particularly good opportunities for provider practices to get paid for monitoring and managing their patients on an ongoing basis:
● 99490 Chronic Condition Management
● 99091 Collecting and Interpreting Physiologic Data

Code 99490 Chronic Condition Management (CCM), provides reimbursement of non-face-to-face care coordination for Medicare patients with two or more chronic health conditions. Related codes for Complex Care Management (99487) and Transitional Care Management (99495) allow providers to get paid for managing other aspects of patient care but are applicable much less frequently, so it behooves provider practices to develop competency in delivering the services and getting reimbursed for the core CCM code, 99490, before attempting to add them on.

Code 99490 was initially published in 2015 but had significant barriers to use that were resolved in 2017. For example, before the change, providers needed to offer 24/7 access to physicians or other qualified health care professionals or clinical staff which greatly limited the number of practices that could meet the requirements to be reimbursed. In essence, this code allows Medicare providers to be reimbursed approximately $43 for managing a patient care plan without a face-to-face visit. This code can be used monthly for each qualifying patient so practices can earn hundreds of dollars a year per patient on top of their current billing if they consistently manage the patient throughout the year. To qualify for reimbursement, the patient must meet a set of criteria including having been seen face-to-face within the prior year and having two or more chronic conditions that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.

The second reimbursement code with significant potential, 99091 Collecting and Interpreting Physiologic Data, provides reimbursement for healthcare professionals who spend time monitoring and reacting to data from devices that patients use outside the office such as glucometers, blood pressure meters, and weight scales, etc. For the first time in 2018, this code allows for separate reimbursement of approximately $59. To qualify for reimbursement, the patient must meet a similar set of criteria to code 99490, except that the patient does not need to have any chronic conditions.

Expect 2018 to be a transitional year for some of these codes. By January 2019, early adopters will have tested the waters proven the value for large numbers of provider practices to deliver these services profitably.

Win-Win for Providers and Patients
There is an indisputable mountain of evidence that these programs can improve patient outcomes more cost effectively than responding to acute healthcare episodes that could have been prevented by proactive monitoring and management. Medicare has attempted remote care management reimbursement programs in the past, but each and every one of them was crippled by undue restrictions, such as only being able to be used in rural areas.

Any practice with a substantial Medicare population that can implement a program to combine managing chronic conditions with remotely monitoring patient data, can deliver an entirely new kind of care that can move the needle for both patient outcomes and the financial health of the practice. Talk about a literal win-win!

Practices do have to overcome two main challenges to realize those benefits—and partnering with a good solutions provider will help with both.
● First, meeting requirements of new reimbursement programs requires a detailed understanding of the rules and constant attention to them as they are stabilized. This makes it very difficult for smaller organizations to keep up and adapt their processes. Smaller practices will need a partner who cannot just inform them of such changes, but help them adapt to them.
● Second, practices need a robust set of technology tools to deliver and document the new services in a reimbursable manner. They need a technology partner who can help them manage their care management workflow, collect and present data in useful and efficient ways, manage patient care plans, and create the documentation required for reimbursement.

Free Resource
Practices should be optimistic because these new Medicare programs offer the first real chance for them to get paid for managing patient care remotely. However, it will require thoughtful preparation and the right technology partner to provide their patients better services and keep their patients healthy while improving their own bottom line. For practices interested in learning more, Get Real Health is offering a free webinar on April 11 and 19, respectively. Visit for registration details.

Mark Heaney is chief strategist and founding partner of Rockville, Maryland-based Get Real Health.

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