Enroll patients
Start with the right patients and a clear yes.
- Eligible patient lists
- Patient consent and documentation
- Cost-sharing explained to the patient
- Initiating visit tracking
Chronic care management · Patient care
Monthly care between visits for patients who need it.
Patients with chronic conditions need attention beyond the office visit. We work with your care team to run a monthly program of check-ins, care plans and the documentation Medicare expects.
Works with your current systemScope and handoffs agreed upfrontBAA before PHI access
A clear scope. A consistent handoff.
Support designed around real practice work.
Chronic care management only works when it runs every month. We organize enrollment, consent, check-ins and time tracking under the direction of your billing practitioner, and keep the record ready for review.
Run the month
Keep regular contact and a current plan.
- Comprehensive care plan upkeep
- Monthly check-in calls
- Medication and appointment follow-up
- Coordination with other providers
Document and bill
Make each month’s work easy to verify.
- Clinical staff time logs
- Escalations to the provider
- Monthly billing summary
- Records ready for payer review
How we begin
A measured start before the work is handed over.
- 01
Confirm the program
We review your patient population, billing providers, payer rules and current documentation.
- 02
Set clinical boundaries
Your providers define protocols, escalation paths and what must always come back to them.
- 03
Start with secure access
Agree on system access and sign a business associate agreement before any PHI is shared.
- 04
Run and review
We work the agreed tasks, document each contact and review open items with your care team.
Questions
Before you get started.
We’ll use an initial conversation to understand the work, the current system and the boundaries your practice needs.
Which patients qualify?
Generally, patients with multiple chronic conditions expected to last at least a year who are at significant risk without management. Your provider makes the decision under current payer rules.
Can a patient say no?
Yes. Participation is voluntary and patients can stop. We explain the service and any cost-sharing before consent is recorded.
Start with a conversation
Let’s talk about the work you want off your team’s plate.
We’ll discuss your workflow and what a practical service scope could look like. Please don’t share patient details on the call booking form or this website.
Or call (844) 874-2236