Welcome to Imagine Health Care LLC

Imagine Health Care: Chronic Care Management

Reward health care providers with incentive payments for the quality of care they deliver.

Our Approach

We take a long-term partnership approach with our clients and are flexible to develop programs to meet our clients’ needs. We always strive to set up win-win partnerships. Excellent patient care and client satisfaction are our two most important goals.

Chronic Care Management (CPT 99490 / CPT 99439)

For 2025, Chronic Care Management (CCM) services are reimbursed for the initial 20 minutes under CPT 99490 and for each additional 20-minute period under CPT 99439. CCM requires at least 20 minutes of non-face-to-face care coordination activities each month on behalf of enrolled patients. Eligible participants include any Medicare or Medicare Advantage patient with two or more chronic conditions.

Benefits to the Patient

Direct phone line to an assigned Care Coordinator who serves as an extra set of ears and eyes for the patient while closing gaps in care. Our nurses are trained to help manage the patient’s chronic conditions between office visits.

Why use CCM?

We assign the same Care Coordinator to the patient and their provider. This establishes a trust with the patient which allows the Care Coordinator to effectively coach the patients with lifestyle changes that improve managing their chronic conditions.

An increased level of efficiency from Care Coordinators ensuring all enrolled patients are contacted every month. Industry leading experts who take a patient focused approach to Chronic Care Management. Chronic Care Staffing is on the forefront of compliance and CMS Care Management Services program changes.

Benefits to the Client

Increased quality metrics and revenue, reduced clinical staff time tending to patients not in the office. Care Coordinators can be assigned monthly concentrations from client helping them complete Medicare required measurements.

What is
Chronic Care Management?

CCM services include at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
Chronic conditions place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline
Comprehensive care plan established, implemented, revised, or monitored

The Centers for Medicare & Medicaid Services recognize Chronic Care Management (“CCM”) as a critical component of primary care that contributes to better health and care for individuals.

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (CPT 99490 / CPT 99439) for non-Face to Face services furnished to Medicare patients with multiple chronic conditions.

Chronic Care Management Benefits

Patient Benefits

Patient education, coaching, and self-management health behaviors.
Medication management and ability to transfer knowledge to physicians and appropriate caregivers.
Tracking receipt of preventative services and recommended quality measures.
Helps to close gaps in care.
Same Care Coordinator Assigned for the monthly calls. (Patient and Provider Engagement)

Provider Benefits

Revenue from CPT 99490 / CPT 99439 Billing:
- For 2025, Chronic Care Management (CCM) services are reimbursed nationally for the initial 20 minutes of care (CPT 99490), with additional reimbursement for each subsequent 20-minute period (CPT 99439).
Additional Services Generated by CCM Calls:
- By connecting with patients more frequently, providers generate additional revenue from services treating issues that wouldn’t otherwise be brought up by the patient. (i.e. scheduling annual wellness visits, lab testing, immunizations, etc.)
Maximize MIPS Incentive Payments:
- CMS is highly focused on improving care coordination and places significant weight on CCM when determining your MIPS score and incentive payment.

From a financial perspective, our approach to Chronic Care Management (CCM) is unique.

Our goal is to use Chronic Care Management (CCM) to accomplish two things for our clients; (1) Capture immediate revenue from CCM 99490 / CPT 99439 and (2) Capture increased future reimbursement for all services using our CCM clinical team. We focus on Value Based Reimbursement (VBR) protocols helping to establish and maximize the highest meaningful and outcome measurements. CMS states effective (VBR) can create a potential 20% increase (or possible decrease) in reimbursements across the board.

CHRONIC
CARE
MANAGEMENT
PROGRAM

From a Patient Care Perspective, our goals are as follows:

Close gaps in care, assist Providers in improving patient outcomes, medication management, assigned coordinator to the same patient group, we are not a call center, we are not an IT 3rd party software vendor, we identify ourselves as part of the Practice and our caller id shows the name of the Practice we work for. Chronic Care Staffing is stronger than any other provider in the marketplace.

Chronic Care Staffing is 100% focused on maximizing CCM participation and revenue.

Our verbal enrollment specialists ensure that all eligible patients are contacted and asked to enroll. Unlike other providers that want you to use their software system, Chronic Care Staffing will work with any Electronic Health Record (“EHR“) software provider ensuring our patient charting is always immediately available to the Provider and staff.

WHY choose Imagine Health Care for your Chronic Care Management Program?

Imagine Health Care Focuses on Closing the Gaps in Care for Your Patients

Chronic Care Staffing closes the gaps in care for your patients by offering a comprehensive set of chronic care management services that includes:

Increased Patient Education/Awareness
Identifying Patients in need of their Annual Wellness Visit (AWV)
Assisting with Medication Refills/Reconciliation
Assisting with Verbal Enrollment Maximizing CCM patient participation
Assisting with Appointment Reminders
Documenting and Reporting Change in Patient Health Status
Referral Coordination
Transition of Care notice to Provider
Chronic Care improves patient engagement and quality of care

Outsourcing Chronic Care Management

Outsourcing Chronic Care Management (CCM) is Proven to Be More Effective than In-House Management

Most of Chronic Care Staffing’s clients started chronic care management internally and did not achieve full potential for two primary reasons:

1. Internal staff are constantly rushed to do other things in the office resulting in lower monthly billed calls. Difficulty in achieving and maintaining the capacity of Care Coordinators to provide high call penetration of enrolled patients. This often requires that each enrolled patient Successful CCM programs have a high ratio of monthly billing per enrolled patient. CCS averages 92% of enrolled patients monthly billed in your CCM program.

2. It is expensive to recruit, train, and retain CCM Care Coordinators, which minimizes the provider’s profitability and its ROI on CCM services.

By outsourcing Chronic Care Management (CCM) with CCS, your practice will:

Generate greater revenue
Increase patient participation
Retain a greater focus on face-to-face care

Proven Hiring Practices Give Your Patients Access to Highly Qualified Care Coordinators

Chronic Care Staffing’s team of care coordinators includes:

RNs and CMAs
Insurance Company Chart Audit Preparedness
Former major health plan auditors and project managers
HEDIS Specialist
Experienced CCM nurses

Extensive hiring process includes:

7 Year background search including state and local records
Reference and Employment Verification
License and Education Verification
Drug Screen
Extensive testing and role play phone exercises
Level 3 FACIS background performed

Patient Resources

DEMOGRAPHIC INFO

AUTHORIZATION AND DISCLOSURE

AGREEMENT FOR PAYMENT