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Chronic Care Management (CCM)

OPM (Online Patient Monitoring) delivers Chronic Care Management (CCM) for patients with two or more chronic conditions. Our CCM services provide virtual, phone-based follow-up and monthly accountability to improve patient outcomes, reduce hospital readmissions and boost the medical practice revenue. We provide patient-centered, practice-friendly services delivered with empathy and efficiency, handling every aspect of CCM so practices can focus on providing the best in-office care. Our expertise in care coordination, regulatory compliance and clinical support has proven OPM to be the ideal partner for medical practices. We've proven our value to providers and welcome the opportunity to partner with you as well.



What is CCM(Chronic Care Management)?

CCM began when the Centers for Medicare and Medicaid Services (CMS) introduced CPT billing code 99490 in 2015 to compensate providers for non-face-to-face care for patients with two or more chronic conditions. Every day, 10,000 Americans turn 65. Chronic Care Management (CCM) relies on virtual (non-face to face) communication with those Medicareeligible patients, who enjoy more efficient access to care and assurance they're staying on track, while providers benefit from a more integrated care approach and a new, highly profitable revenue stream.


More features:

  • CCM services complement regular inoffice visits, reducing the need for certain routine appointments.
  • Improved access for patients while reducing ED visits and hospitalizations.
  • 20+ minutes of remote clinical support every month by licensed nursing professionals
  • Enhanced monitoring and coordination of care between office visits
  • More consistent patient engagement
  • Increased monthly practice revenue and profitability
Chronically ill patients account for the majority of all emergency room visits, many of which are preventable. Our services work to reduce those visits through preventive care. According to CMS, CCM is increasing patient and practitioner satisfaction and saving costs but continues to be underutilized by practices.



CCM Helps Both Patients & Providers

  1. Enhanced monitoring and coordination of care between office visits

  2. Improved access for patients while reducing ED visits and hospital readmissions

  3. Peace of mind in the event of a CMS audit of the practice

  4. Guidance and encouragement to follow a plan of care

  5. Increased practice revenue 05 and profitability




Why Partner With OPM (Online Patient Monitoring) for Chronic Care Management Services (CCM)

Effective CCM means having the know-how, systems, staff, and processes to make it work. OPM's (Online Patient Monitoring) comprehensive approach is truly A Better Way to Care:

Next-level EnrollmentOur Enrollment Program (EP) is essential to the success of your CCM program.We partner with practices and provide access to our app to on board andeducate patients about the program's value, while ensuring CMS compliance.The average in-house enrollment program enrolls 10 percent or less of eligiblepatients, while OPM achieves enrollment rates of 50% and more. Here's how it works:

  • Identification of Eligible Patients: Our data team accesses your ElectronicMedical Records (EMR) system to identify patients who are eligible and a good fit for CCM
  • Enrollment Calls & In-Practice visits: Our specialized enrollment team contacts patients, educating and enrolling those who consent, partner with your clinical staff enroll consenting patients that are visiting the practice, through our proprietary app.
  • Documentation: We document patient consent for compliance purposes and provide you with outreach results
  • Update: we review our patients population regularly to ensure all eligible patients are given an opportunity to join the program




  • Chronic Care Management services provide new, meaningful, recurring revenue to a practice.
  • Potential financial benefits to practices associated with CCM:
  •     500 Enrolled Patients = $120,000 potential increase in profit per year
  •     1500 enrolled patients = $360,000 potential increase in profit per year
  •     Large Health Care Systems can realize profit margins in the millions of dollars



Our proprietary workflow-based process ensures that all patients are serviced consistently, thoroughly, and securely regardless of assigned Care Coordinator. A physician's general or patient-specific instructions can be included with confidence.

Best of all, our Care Coordinators handle all administrative aspects, eliminating the need for practice staff to learn new procedures and processes.

OPM's dedicated Care Coordinators focus on helping your patients reach their health objectives, providing encouragement, answering questions, and connecting them to resources.

Convenient: Patients are contacted by their Care Coordinator at a convenient time, in the comfort of their home. We make multiple attempts to speak with patients each month

Proactive: Care Coordinators ask questions targeted to a patient's specific conditions, identifying problems early, and preventing unnecessary and costly hospital visits

Empathetic: We train Care Coordinators for intentional listening, responsiveness, and compassion. We treat each patient as we would our own loved ones. Each Care Coordinator is evaluated against this standard in our quality assurance audits

Effective: Our high rate of monthly patient contact maximizes adherence to care plans and provider-prescribed treatments
Another focus of the program that OPM provides for CCM, is its meticulous documentation of the time a Care Coordinator spends on patient interactions, ensuring all CCM services are fully compliant. CMS periodically conducts routine audits to validate billing practices, and we're always prepared by maintaining extensive data trails.

The security of protected health information (PHI) is a top priority of ours, ensuring it stays private in full compliance with all HIPAA standards.

As Chronic Care Management (CCM) becomes more and more accepted as a preferred means for treating patients with chronic conditions, CMS continues to update regulationsaffecting healthcare providers. We stay on top of these updates, refining our processes and letting providers know about changes affecting reimbursement and program features.

Let us show you the difference OPM (Online Patient Monitoring) can make for your practice, your patients, and your revenue cycle by implementing and maintaining virtual care programs.

We improve patient care, deepen patient-practice relationships, and increase practice revenue without adding cost. If you're interested, contact us today. Our programs can be set up and running in just a few weeks.

Let's work together to empower your patients and optimize your practice.





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