What is Chronic Care Management?

Initial Consultation and
Risk Assessment

We provide a monthly phone call conducted by one of our RNs. We first identify the patient’s risk level based on a thorough questionnaire and based on this assessment, established the patient’s health-related goals.

Ongoing 24/7/365
Patient Support

In addition to 24/7/365 text and call support, our RNs will help schedule doctors appointments, provide ongoing education, ensure medication adherence and provide ongoing accountability.

Bill the Payer for
Providing CCM

Our clinical interactions with your patients generates time towards the time-based CCM codes that you will bill Medicare (or other payer) for monthly. We help you with billing details so that you can generate clean claims.

Who monitors the patient data?

Our Clinical Team

Our Clinical Team

Our clinical monitoring team of nurses and MAs monitors your patients 24/7, responding to readings, calling, assessing and escalating relevant cases to you.

Our Software

Your team will have access to our web-based, HIPAA-compliant RPM/CCM platform which serves as the hub for both programs.
Our Software

How much will get reimbursed for CCM?

Up to $160 per patient, per month.


20 Minutes - CCM

99490: Initial 20 minutes of clinical staff time. Average $64.

40 Minutes - CCM

99439: Subsequent 20 minutes of clinical staff time. Average $48.

60 minutes - CCM

99439: Subsequent 20 minutes of clinical staff time. Average $48.

How will this benefit our patients?

-16 mgdl

Our clinic's average blood glucose improvement overtime

-11 mmhg

Average systolic blood pressure improvement overtime

-9 mmhg

Average diastolic blood pressure improvement overtime

-4 bpm

Average resting heart rate improvement overtime

-17 lbs

Average weight loss improvement overtime


Medication adherence increase

How will you keep our patients engaged?

Automated Reminders

In addition to our live agents who call patients, our automated reminder system will send SMS reminders to patients to remind them to take their readings.

Consumables Included

We supply patients with consumables for their devices, including batteries, diabetic lancets and test strips as part of our service.

Care Coordinators

When enrolled in our CCM program, every patient will be assigned their own personal care coordinator. Developing a trusting, and meaningful relationship with patients will ensure long-term adherence.

How do we get started?


Receive Analysis

Receive a complimentary analysis of how many patients qualify for RPM and CCM, along with your estimated costs and reimbursement.


Ship Devices

Once patient consent has been obtained, will ship devices and consumables to your patients' homes.


Get Reimbursed

We'll provide a monthly billing report so your biller can easily generate RPM and CCM claims.


Get Consent

Our team will call patients to educate them about RPM and CCM and obtain their consent.



Our RNs will call your patients when their readings are abnormal and escalate appropriate ones to your attention.

Enhanced Patient
Enhanced Care.

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