CMS Changes in Chronic Care Management

Description

The U.S. Healthcare Insurance market is undergoing a period of change. There is building momentum among Governmental officials to initiate these changes by implementing new payment models starting with the Medicare system. The goal is to transition from a procedure-based physician fee model to an outcomes-based care coordination team approach that will achieve success by virtue of reduced costs and much improved patient awareness. An important aspect of these efforts will be to devise interpersonal and technical ways that will stimulate improved patient adherence to prescribed prescription and health maintenance plans towards the expected outcome of reduce need for preventable medical interventions. In January 2015, the CMS implemented a new Current Procedural Terminology code: CPT® 99490. This code will make certain non-face-to-face patient communications and care coordination efforts reimbursable at a low level on a monthly basis for Medicare beneficiaries who have two or more defined Chronic Conditions. The following Insights document examines this issue and the implications that must be clearly understood by providers and consumers. It provides a view of the various pros and cons as well as a summary of the great number of questions this new capability is likely to spark at a time when much more dramatic sweeping changes are about to be phased in over a long-term period.

Contents
Introduction
What Must the Medical Practice Consider?
What is the impact on telehealth?
What is the Payoff for the Provider?
Situation Analysis
Pros
Cons
What Comes Next?

Exhibit 1 – Health Insurance Marketplace, High-level View of CPT CCM Workflow, US, 2015
Exhibit 2 – Health Insurance Marketplace, New CPT and HCPCS Telehealth Codes, US, 2015
Exhibit 3 – Health Insurance Marketplace, Revenue Scenario Estimates, US, 2015
Exhibit 4 – US Insurance Market, Medicare - CCW Condition Period Prevalence, US, 2012