Medical Group Management Association
Join Now
Top House Ad

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

Insight Article - September 24, 2021

Population Health

Patient Care Technology

Value-Based Operations

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:

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.

Sign in to access this material

Member Login Become a Member

About the Author

Kelly Ladd
Kelly Ladd FACMPE

Shopping Cart

Your cart is empty

Click here if your organization is tax exempt

A State Sales tax exempt certificate must be on file and taxable items cannot be ordered online. For immediate assistance during normal business hours of 7:00am to 5:00pm MT M-Th and 7:00 am to Noon MT on Friday, please call toll-free: 877-275-6462, ext. 1888



Use two letter code for US states
Use three letter code for country
Use two letter code for US states
Use three letter code for country
Use two letter code for US states
Use three letter code for country

Grand Total:
Saved credit card is required for opt-in to autorenew.

Questions? Contact the MGMA Service Center for assistance during checkout or review our return policy for more information.




Thank you for your purchase! If you purchased an event, you will be receiving a follow-up email from our Learning Management System regarding the product/event purchased and no further action is required.