How Healthcare Is Changing Care Management Reimbursement Models

At Welkin, we believe in person-centered healthcare. That means prioritizing the user experience above all. Whether a patient is battling a chronic illness or learning to live with a life-changing diagnosis, we want to make the time they spend with care teams as painless as possible so they can focus on healing. It’s our responsibility to help change the care management landscape for the better—and it’s not something we take lightly.

A shifting healthcare landscape means changes for Care Management reimbursement

With the transition from traditional healthcare business models to value-based Care Management underway, it’s an exciting time for healthcare organizations. According to NEJM Catalyst, value-based healthcare is defined as “a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes.”

This new and improved Care Management reimbursement model incentivizes healthcare providers to improve access to care for all populations and make sure that patients actually get value out of the care they receive—instead of just doing medical tests like CTs, MRIs, and PETs so they can get paid more money.

An excellent example of value-based healthcare can be seen in the Centers for Medicare and Medicaid Services (CMS) Hospital Value-Based Purchasing (VBP) Program, which, based on the quality of care provided, rewards acute care hospitals with incentive payments adjusted under the inpatient prospective payment system (IPPS).

Designed to improve patients’ quality of care and create an overall better hospital experience, the VBP Program rewards hospitals annually based on how they performed compared to competitors, and how they improved from the year prior—and there’s always room for improvement!

What you really need to know about Care Management reimbursement

Care Management reimbursement is an incredible system that benefits both the patient and their care provider. However, to understand how the Care Management reimbursement model works, we need to first explore what Care Management is all about.

What is Care Management?

Care Management improves patient care and significantly reduces the need for medical services. It’s the set of activities designed to teach patients how to manage their health conditions more effectively and improve health outcomes. Care Management programs work to enhance care coordination and help patients improve their quality of life.

How is Care Management billed?

Patients must give written or oral consent that allows their clinician to bill for Care Management services. Only one care provider (typically the primary care physician) can provide and be compensated for Care Management services in a calendar month. Copayments still apply to services, unless those services are provided during the patient’s annual visit.

What are the CPT codes for Care Management reimbursement?

There are a few key CPT (Current Procedural Terminology) codes used for chronic Care Management, complex Care Management, and remote patient monitoring.

CPT codes 99490 and 99491

The CPT codes 99490 and 99491 are used for chronic Care Management services performed for at least 20 or 30 minutes, respectively, each calendar month. Your patient needs to have two or more chronic conditions that are expected to last at least 12 months, or until death. The patient’s comprehensive care plan must be established, implemented, revised, or monitored to qualify for Care Management reimbursement.

The 2018 average reimbursement for CPT code 99490 is $42.84.

CPT code 99487

This code is used for complex Care Management services performed for 60 minutes each calendar month. “Complex” Care Management is defined as moderate- or high-complexity medical decision-making. Your patient must have two or more chronic conditions that are expected to last at least 12 months, or until death. The patient’s comprehensive care plan must be established or go through substantial revision.

The 2018 average reimbursement for CPT code 99487 is $94.68.

CPT code 99489

This code is used for each additional 30 minutes of complex Care Management services and is reported in conjunction with CPT code 99487. The 2018 average reimbursement for CPT code 99489 is $47.16.

CPT code 99091

This code is used for a minimum of 30 minutes of remote patient monitoring. This includes clinicians’ collection and interpretation of physiologic data—such as ECGs, blood pressure, and glucose monitoring—that is digitally stored and/or transmitted by the patient. The 2018 average reimbursement for CPT code 99091 is $58.68.

Strategies for Care Management reimbursement

Value-based care is vastly different than traditional pay-for-service models. Since clinicians are not paid for each service delivered, they need Care Management reimbursement so they are able to administer adequate patient care and improve health outcomes.

Here are some things you can do at your healthcare organization to ensure that you are properly reimbursed for Care Management services.

Make sure your program fits the definition of Care Management

In order to receive Care Management reimbursement, your healthcare organization needs to make sure that it is fulfilling the requirements of an effective Care Management program.

• Utilization of digital health tools – The creation and regular revision of an electronic care plan is crucial to a successful Care Management program. Clinicians must also use an EHR (Electronic Health Record) to bill Care Management codes.
• Contact-based care – Care regarding the patient must be contact initiated via phone or electronic communication. A Care Management platform can help your staff organize all communication in one place and keep things coordinated.
• Medication management – Medication reconciliation—with the review of adherence and potential interactions and oversight of patient self-management of medications—should be included in each comprehensive care plan.
• 24/7 access – Medicare patients need 24-hour access to their primary care physician or other qualified healthcare professional to address medical emergencies and other urgent matters.

Determine if your team is ready

Implementing a Care Management program requires sweeping support from not only leadership but all healthcare staff, as well. An intentional culture shift is vital, as are well-established job roles and workflows. Coding, billing, and health information technology staff need to be involved in the transition to a Care Management program. Every care team member that will have contact with patients needs to be engaged and in support of the changes—including social workers, pharmacists, nurses, and dietitians.

Track all communication between patients and care providers

The best way to monitor, analyze, and improve your Care Management program is by tracking all communications with patients in a Care Management platform. Healthcare staff should be properly trained in communication best practices, and be sure to track each and every touchpoint for both billing and care plan revision purposes.

Real outcomes and results

We’re proud to help our customers see real results when using our Patient Relationship Management platform. With Welkin, clinicians can help their patients navigate diagnoses in real-time and empower them to engage in their own healthcare. Many patients have learned how to self-manage diabetes and reduce A1c, among other life-changing accomplishments.

Gathering patient data is also a huge benefit to your healthcare organization. For example, drop-off rates in type 2 diabetes management can contribute to worsening symptoms. If care teams are able to intervene when patients aren’t engaged with Care Management systems, health systems can better control costs and optimize resources.

An increasingly nonexistent technology divide

With Care Management, are one step closer to completely eliminating the technology divide. Patients of all demographics have adopted technology as part of their healthcare journey. Thanks to widely accessible technology, you can text or video call just about anyone today, no matter who they are.

This dissipating technological divide means that integrating digital tools into Care Management is a sustainable option. Telehealth can also help provide care to patients who live in rural locations and have limited access to healthcare services. Through digital tools like video conferencing software, doctors can help patients without leaving the hospital (or making the patient leave their home).

Consumerism of healthcare

Healthcare consumerism is a movement that’s making healthcare services more efficient and cost-effective. It empowers patients to become increasingly involved in their healthcare choices. Rather than showing up to the same local healthcare center and getting mediocre care for fixed prices, healthcare consumerism encourages patients to “shop around” for options. It drastically improves not only the communication between healthcare providers and patients but outcomes, as well.

Wearable technology and digital tools make Care Management possible

Although this movement is still new, it’s clear that it has the power to change the way we approach American healthcare forever. Through wearable technology (like Fitbits and Apple Watches) and digital tools (such as Care Management software and patient portals), information is readily available and patient engagement is at an all-time high. By tracking statistics like their heart rate, sleep patterns, and calories burned, patients are taking an active interest in their health.

Even though it hasn’t been a priority in the past, there’s no denying user experience is becoming fully integrated into the overall design of healthcare services. Patient-centered healthcare is here to stay, and we couldn’t be more grateful and excited for what the future holds.

A bright future for patient-centered healthcare

This industry has come a long way, but there is still a ways to go. With the integration of digital tools and a massive shift in healthcare culture, we have high hopes that things will drastically change to benefit the patient experience.

To learn more about how to improve the patient experience at your healthcare organization, check out our ebook How to Deliver Value-Based Care.