Scaling Chronic Care Management: How a Texas Health System Manages 8,000+ CCM Patients
Austin, Texas
Overview
A large Texas health system needed to scale their Chronic Care Management (CCM) program to serve Medicare patients with multiple chronic conditions. The challenge: managing 20+ minutes of monthly care coordination per patient while documenting everything for CMS billing compliance.
BeyondRxAid built an enterprise platform that automates care plan management, tracks billable time, integrates remote monitoring devices, and provides care coordinators with a unified view of patient status—enabling each coordinator to manage 3x more patients.
The Challenge
Medicare's CCM program offers significant revenue opportunity ($42-140+ per patient per month), but requires detailed time tracking and documentation. The client faced several challenges:
- Scale CCM program from 2,000 to 8,000+ patients without proportional staff increase
- Track and document 20+ minutes monthly per patient for CMS billing
- Integrate data from 15+ remote monitoring device types
- Automate care plan creation based on patient conditions
- Provide real-time alerts for out-of-range vitals and missed check-ins
- Support Medicare billing codes: 99490, 99491, 99487, 99489
- Integrate with Epic EHR for seamless clinical workflow
Our Solution
We built a comprehensive CCM platform with care coordinator dashboards, patient mobile apps, and billing automation:
- Web-based care coordinator dashboard with patient prioritization algorithms
- Automated time tracking with activity logging for CMS compliance
- Care plan templates auto-populated from problem list and medications
- Device integration hub supporting blood pressure, glucose, weight, pulse ox monitors
- AI-assisted call scheduling based on patient risk scores and engagement patterns
- Automated billing report generation with CPT code assignment
- Epic integration via FHIR APIs for bi-directional data sync
- Patient mobile app for vitals entry, medication reminders, and messaging
- Supervisor dashboard with coordinator productivity metrics
Results Delivered
4x Scale
Scaled from 2,000 to 8,000+ CCM patients in 18 months
3x Efficiency
Each coordinator now manages 250+ patients (up from 80)
$2.4M Revenue
Annual Medicare CCM revenue generated
94% First-Pass
Claims approved on first submission
- 35% reduction in ER visits for enrolled patients
- 22% improvement in medication adherence
- Full Epic EHR integration with bi-directional data sync
Tech Stack
Medicare CCM Billing Codes Supported
- 99490: 20 minutes of clinical staff time (≈$42)
- 99491: 30 minutes of physician/QHP time (≈$83)
- 99487: Complex CCM, 60 minutes (≈$93)
- 99489: Additional 30-minute increment (≈$46)
Ready to Scale Your CCM Program?
Let's discuss how we can help you increase CCM revenue while improving patient outcomes.
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