Expanding patient outreach services: Better care and patient experience while generating new revenue streams

Editor’s note: This article was adapted from a paper submitted toward fulfillment of the requirements of Fellowship in the American College of Medical Practice Executives. Learn more about ACMPE certification: mgma.com/acmpe.

Piedmont Internal Medicine is a well-established adult internal medicine practice. The initial development of its WellTouch program was designed for patient outreach as a value-added service to existing patients, by using dedicated staff to follow up with chronic care patients in a proactive and personal manner to promote wellness through annual physicals and treatment plan compliance. Over the past four years the program has grown to include quality metric reporting to our affiliated health system, Medicare, and commercial insurance carriers. 

About Piedmont

Piedmont Internal Medicine, PC is a privately owned independent internal medicine group made up of 12 physicians and four APPs who provide primary care services for adults. There are currently more than 28,000 active patients in PIM’s database. 

Despite more than 16 years of clinical data showing substantial savings to the Medicare program and health benefits to patients involved in a chronic care management (CCM) program, most primary care physician practices have not adopted proactive health programs such as remote care or CCM. Some of the roadblocks in implementing such plans included Centers for Medicare & Medicaid Services (CMS) requirements, which dictated that only a licensed provider could render chronic care services.

The restrictions, coupled with very low reimbursement for time to bill for chronic care services, created very little incentive for practices to implement successful proactive CCM programs. In recent years, CMS has revised remote care patient monitoring and CCM billing requirements and reimbursement.   

In 2018 CMS expanded remote patient care coding and revised CCM effective Jan. 1, 2021. These changes allow the physician to prescribe remote monitoring equipment, staff to bill for daily monitoring of the remote equipment data captured and reported, and the patient and staff to interact regarding the equipment and data results in cumulative time increments. If the patient meets the minimum CMS-defined criteria, a chronic care treatment plan can be created by the physician, allowing a non-licensed staff member to render some chronic services as “incident to” (under the direct supervision of the physician). CMS has also increased reimbursement for these services, making it possible for a practice to implement and sustain a successful CCM program. The changes stated above — combined with new enhanced remote care equipment technology, the onset of the COVID-19 crisis, and telemedicine — have created unique opportunities to expand the WellTouch program.

Planned business model

WellTouch is an incorporated business under the umbrella of Piedmont Internal Medicine, PC for branding and marketing purposes. The daily operations will be performed by certified medical assistants (CMAs) who identify and call patients to follow up with abnormal test variances in remote care monitoring, and maintain follow-up visit intervals within the guidelines of standard operating procedures. Since there is a billing and coding element with the program, the director of business operations is responsible for daily operations. Follow-up or interventional care appointments are made with the advanced practice provider (APP) or physician.

Strategy

New technologies allow new services to be added to the WellTouch program without the need for patients to use a smartphone or manually enter daily monitoring results online. Due to the practice’s significant number of existing patients, WellTouch can target existing patients over 65 who already meet the CMS-required criteria of having at least two significant chronic conditions. Once these patients are identified, the modes of marketing contact will include use of email letters through the patient portal section of the EHR, mailers signed by the patient’s physician, brochures, and in-person introduction to the services during appointments. Once patients have been introduced to the program, a consent to treat form must be signed by the patient, and a treatment plan will be developed by the provider. 

WellTouch staff then begin enrolling patients into the program, and equipment will be drop-shipped to patients by the vendor. A WellTouch representative will call patients to assist them in setting up the equipment and review the prescribed treatment plan. Daily monitoring and cumulative monthly reporting follow. Since the codes require a cumulative recording of time, billing for these services will be completed at the end of each month. The long-term goal is to have all patients with chronic care conditions, regardless of age, enrolled in the WellTouch program. 

Services

WellTouch services involve quality patient assessment metrics review, documentation, and reporting for CMS, commercial insurance carriers, and the Piedmont Clinic/Piedmont Healthcare ACO. These services include proactively calling patients from internal reports generated from the practice’s EHR and from member listings generated by the insurance carriers to personally connect with the patient to ensure compliance with preventive care services (e.g., mammograms, colonoscopies, annual physicals and other wellness exams) and CCM.

The current services will continue in conjunction with the new remote care monitoring service and CCM service. The remote care monitoring equipment is securely paired with a control hub via Bluetooth. The control hub has a cellular SIM card chip that securely captures the data and transmits it to a secure database portal managed by the vendor. Presently, the remote care vendor can offer a scale, oximeter, glucose reader, thermometer and blood pressure device. All patients 65 and older with two or more chronic care diagnoses will be introduced to the remote care program as the first step with CCM services. 

The combination of patient lists and reports from insurance carriers, the Piedmont Clinic/Piedmont Healthcare ACO metric reports, the remote care equipment vendor, and internal reports from the practice’s EHR will comprise the CCM service. The practice’s EHR has developed a CCM module in which further documentation can be made using various templates and reports. This gives WellTouch the ability to centralize, streamline and process all data for the Piedmont Internal Medicine, PC patient population.

Initially, billing for remote care and chronic care services will be completed through the remote care vendor’s software. Patients who only wish to be enrolled in the CCM program will be billed through the practice’s EHR. There are plans, however, to create an interface with the practice’s EHR to capture all data. The time frame for the interface has not yet been established.

Potential operational roadblocks and resolutions 

Earlier in 2021, new enrollment into the RCM program stalled due to staffing issues related to the COVID-19 pandemic, as finding additional staff became extremely difficult. We partnered with our remote care equipment vendor to incorporate a full turnkey solution that included using registered nurses (RNs) to be the frontline patient outreach staff.

We established care coordination teams with our vendor and internal staff. The remote care nurse works for our remote care vendor as a W2 employee but is tied to the practice via contractual agreement. This is important for compliance reasons, as these nurses need access to our EHR for documentation and internal clinical messaging regarding patient care.

The care teams were created to establish continuity and relationships between the remote care nurse, the patient, the provider and practice staff. This was done by assigning a remote care nurse to a physician and the physician’s patients. We also changed the job descriptions of our internal WellTouch patient care representatives to a liaison role to assist the physicians with patient enrollment while the patient is in the office; assisting the remote care team nurses in making telemedicine or office visit appointments with the providers as needed for patients who are trending “out of range” monitoring values; and as internal support of the program team members as a full patient care team. A full patient care team includes our internal liaisons, the physician/provider, the provider’s medical assistant(s), and the remote care RNs.

A secondary concern is creating the operational ability to streamline current WellTouch services efficiently and effectively into the new services. There are many overlapping sectors of data capture and reporting without duplicating work or creating additional work due to inefficiency. The streamlining of some of the operational procedures and processes will result in “trial and error” as overlaps are identified and streamlined solutions become apparent. Once they become apparent, improved processes can be created and implemented into standard operating procedures.

Financial analysis

Staffing resources

WellTouch expenses have been minimal over the past four years with one full-time CMA managing the current operations with minimal oversight.

The expenses associated with RCM and CCM services are based on patient volume. As patient volume increases, direct expenses also increase. The capital requirements for this business plan are based on incremental growth related to patient volume over a two-year period.

Immediate resource requirements entail two full-time CMAs working as WellTouch representatives for the first six months. WellTouch and Piedmont Internal Medicine, PC have some coordinated operational workflows that are streamlined into patient care provided by physicians and APPs; thus, there are overlapping and separate expenses that include current staff of CMAs, APPs, RCM equipment costs, additional software and interface expenses, and management oversight. Computers, telephones and workstations are already available from past FTE attrition. It is estimated WellTouch will have 600 patients enrolled in the program within the first four to six months. Equipment for the remote monitoring is billed to the practice when it is dispensed and is based on the equipment prescribed by the physician, typically four per patient. The cost per piece of equipment depends on the equipment itself. Allocation of capital for the first six months is estimated to be $136,204. As more patients are enrolled in the program, capital expenditures will increase incrementally and are directly tied to increased patient volume. 

As the number of patients enrolled in the program increases, additional staff will need to be hired. Six full-time CMAs are projected for management of remote care patients, as well as the hiring of at least one additional APP within the first year. Total staffing costs for the first 12 months are estimated to be approximately $297,600.

Office supplies and operations

The office was estimated to incur an additional $180,815 for office supplies, telephones, computer workstations, claims processing, marketing and general operational costs. The overall additional expenses for office supplies and equipment over the initial 12-month period ended up being more than $50,000. This was mainly due to the lack of growth internally and expenses being shifted over to the remote care nurses. 

Laptop computers were purchased for the remote care nurses to comply with HIPAA and cybersecurity measures. Our IT vendor specifically configured computers to allow the remote care nurses to document into our EHR and to comply with our internal IT protocols and our EHR vendor protocols.

In addition, the remote care nurses are required to adhere to our internal corporate compliance and HIPAA policies and procedures.  This includes signing confidentiality statements, completing our practice required training as it pertains to computer security and compliance, and other patient engagement protocols as established within our practice.

Remote care monitoring

There is a one-time cost for the monitoring equipment, which will mainly consist of the data hub (cellular device transmitting data to the data capture software), a digital thermometer, a digital blood pressure cuff and gauge, and a digital pulse oximeter device (basic package). The cost of the combined equipment is $241. There is a manufacturer guarantee for defective equipment; however, if a patient breaks a device, they will be responsible for the cost. If the physician prescribes a digital glucose monitor at $44 and/or scale at $32, these items will be added to the cost of the $241. There is also a monthly $35 per patient monitoring and vendor service charge. There may be opportunity to negotiate with the vendor to have a set fee per patient per month to include equipment and services, therefore spreading out the initial cost of the equipment until ROI is fully realized. The estimated cost of equipment within the first 12 months for 2,000 patients will be approximately $924,236, and at 24 months for 4,000 patients will be approximately $1,869,80. In year two, however, the cost of equipment will be around 40% lower due to growth potential peaking by the end of that year. Once peak growth has been realized, there will be minimum equipment expenses outside of replacement and new patients coming into the program.

The cost of the RCM equipment is fully reimbursable by insurance. Monthly reimbursement per patient per month on the remote care side with the basic package based on CMS data is estimated at $132.87, which includes CPT® codes used for RCM: 99453 (initial setup and education, $19.12), 99454 (monthly equipment fee, $63), and 99457 (first 20 minutes of engagement, $50.75). With CPT® code 99458, there is opportunity for additional reimbursement of $41 for each additional 20 minutes of engagement.

The average reimbursement per patient per month is around $160, with the intention of reaching 4,000 enrolled patients by the end of the second year, at which point gross collections are estimated around $4.84 million.

Chronic care management

A sampling of potential chronic care patients was taken from diagnosis reports with filters to identify patient age and Medicare insurance (traditional and Medicare Advantage patients) to estimate reimbursement for CCM. It is estimated that 35% of the current active patient population meets the CMS criteria for CCM services. Reimbursement based on CPT® code 99490 and HCPCS code G0506 (care plan creation) is estimated to be $106 per patient for the first month, then $42 per patient per month. These codes are billable as incident to services and are not required to be rendered by licensed personnel. There is mandatory oversight by a provider as the provider must sign the plan of treatment and review and sign off on all documented interaction between the patient and the staff. There are additional CPT® codes that can be utilized by a licensed provider (physician or APP) and billed for more complex patients through telehealth services. Overall gross collections for the CCM at 35% of all enrolled RCM patients was estimated to be $372,680. With extra staffing resources through the remote care nursing service, that rate has increased to 45%.

Combined service overview

The program is based on patient volume, so expenses and revenue will increase as patient volume grows. Once the billing and revenue cycle build into a steady rolling cycle, the estimated first year (consecutive 12-month cycle) net profit will be approximately $402,750. First-year profits are not as robust as subsequent years due to several factors, including:

• The revenue cycle specific to remote and chronic care billing and reimbursement
• Upfront cost of remote care equipment dispensed to the patient, which was later changed to an equipment subscription to spread the cost of the equipment over 12 months, giving faster ROI to the physician
• Full and consistent ROI not realized until month six. 

The monitoring and chronic care codes are cumulative and rolling, thus the more patients enrolled, the more billed and the higher the revenue. Since implementing the full turnkey service, patient enrollment has grown. At the end of the initial 12 months, we had 1,200 patients — lower than the original projections based on our payer-mix percentage of total Medicare patients. We continue to enroll patients and hope to have 2,000 enrolled in the RCM program by the end of this year.

We forecast the practice will have a net profit estimated at $1,478,150 with at least 2,000 patients enrolled in the RCM program at the end of the 24-month period. Through June 2021, year-to-date gross collections topped $670,000, with overhead around 55% in total, leaving an estimated net profit of $300,000 on just the RCM side. At the end of year two all “front-ended” expenses, especially staff expenses, have been allocated and leveled out, thus yielding a much higher profit level than year two.

Key assumptions with expectations around ROI

Added services to the current WellTouch program are based on patient volume. These assumptions include:

• Patient lists will be generated from the current EHR by filtering fields such as active patients, age and insurance. For example, the program will start with active Medicare and Medicare Advantage patients. There is no cost associated with the production of the reports.
• Patient enrollment will come through direct mail using the EHR patient portal (or via letter if the patient is not signed up on the patient portal), internal website promotion, office brochures, and physician or APP recommendations. There will be a separate webpage within the PIM website dedicated to RCM and chronic care. The cost is already embedded within the website maintenance fee and a part of the 6% overall practice operations allocation for WellTouch.
• Overall patient enrollment volume was anticipated to be around 65% of the practice’s eligible Medicare population, and the program’s initial retention rate is 87%, exceeding the long-term projected retention rate of 85%.
• RCM equipment cost varies depending on how many pieces of equipment are prescribed. At minimum, each patient will be dispensed a communication hub, pulse oximeter monitor, blood pressure cuff, and thermometer with a total up-front cost to the practice of $241 per patient. Additional equipment costs could include a glucose monitor for $44, glucose strips for $6.50 (month supply), BMI scale for $32, and/or spirometer for $81. 
• There are minimum billing requirements set by CMS that the patient must complete daily monitoring for 16 consecutive days prior to billing for the equipment (CPT® code 99454) and the patient monitoring with staff interaction must meet a minimum of 20-minute increments per month (CPT® codes 99457 and 99458). If the 20-minute minimums are not met for each code, they cannot be billed.
• Reimbursement for RCM is based on initial set up and education, equipment monitoring and patient engagement. The first month of reimbursement is typically between $132.83 and $175.05 per patient, depending on insurance and captured monitoring and interaction minutes between the equipment, patient and staff member. The second month of reimbursement is typically between $114.06 and $156.28 per patient; thereafter reimbursement based on Medicare should be around $114.06 per patient per month for the period of enrollment.
• CCM expenses are tied directly to the WellTouch staff and EHR software interface fee of $2 per patient per month. Reimbursement is based on CPT® coding services billed, which include a one-time treatment plan for Medicare patients and CPT® codes based on time intervals of patient interaction via telemedicine between WellTouch representatives and/or providers of Piedmont Internal Medicine, PC. After the first month, billing will be based on the CCM CPT® codes using time intervals of patient interaction via telemedicine between WellTouch representatives and/or providers of Piedmont Internal Medicine, PC.
• CCM reimbursement directly tied to the WellTouch representative(s) during the first month of enrollment has been estimated to be $106 per patient based on Medicare’s fee schedule, and around $64 per patient thereafter for as long as the patient is enrolled in the program. 
• Provider billing and reimbursement for CCM will vary depending on whether the patient comes into the office for a traditional office visit or utilizes the telemedicine CPT® codes — 99441 (CMS $46.13), 99442 (CMS $76.04), or 99442 (CMS $110.28) — specific to chronic care. Revenue generated by the providers is difficult to predict as patients are required to come into the office at regular intervals for follow-up care in between their required physical exam, per standard of care guidelines set by the American College of Physicians — Internal Medicine. We had a 10-patient pilot to analyze and create more efficient workflows to incorporate this piece into the program, with full implementation slated for mid-September 2021.
• Due to the total practice volume of patients and resources, the program will be rolled out incrementally by provider and the number of total active Medicare patients in their patient panel. This will be done as to not put unnecessary strain on practice resources such as cash and staff.
• It is projected the program will reach 4,000 patients by the end of 2022. The pro forma continues at 4,000 patients for year two, and year three, as many of the physicians within the practice have been established for many years and aren’t accepting new patients, which will limit growth. It is anticipated any potential growth from existing patients who fall into either the age categories or develop chronic conditions will be offset by patients who decide to leave the program due to noncompliance. 
• Piedmont Internal Medicine, PC is looking to hire new physicians, and as the practice grows it is anticipated that the program will also grow with the influx of new patients. The anticipated long-term growth is estimated to be between 200 and 400 patients per year.
• Future operational expenses should remain steady as a percentage of the overall practice operational budget of 6% will include inflation.

Innovative elements and expected outcomes

Studies suggest approximately 71% of the total healthcare dollars spent in the United States are associated with at least one chronic condition; among Medicare beneficiaries, 93% of total Medicare spending is directly tied to patients with multiple chronic conditions. A large proportion of these costs is for acute hospital care and emergency department visits that could have been prevented with earlier intervention.1 CMS has estimated that with the implementation of RCM and CCM into a primary care practice, around 17% in overall expenses can be saved per patient per year.2

Although multiple studies have shown the correlation between better patient health outcomes and cost savings with chronic care programs, they have been very difficult to implement in physician practices due to past CMS regulations. Low reimbursement compared to time and expense limited the cost effectiveness for many internal medicine practices.

The WellTouch program has been designed to meet multi-faceted needs that will lead to many positive outcomes and opportunities involving patient care, patient safety, patient outcomes, community impact and additional business opportunities.

WellTouch and Piedmont Internal Medicine, PC have just begun implementation of the new services and are in the process of developing policies and procedures to streamline all the processes mentioned in the plan. 

The expected outcome is very favorable to the overall mission of WellTouch, which is to promote health and wellness in our community, expand appropriate revenue opportunities for the practice, and be a successful model for other healthcare facilities to emulate.

Notes:

1. Degala S. “Chronic care management: Leveraging a significant new revenue stream and reducing costs.” MGMA. April 3, 2019. Available from: mgma.com/ccm-degala.
2. Kadu MK, Stolee P. “Facilitators and barriers of implementing the chronic care model in primary care: a systematic review.” BMC Family Practice. Feb. 6, 2015. doi: 10.1186/s12875-014-0219-0. PMID: 25655401; PMCID: PMC4340610.