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Frequently Answered Questions (FAQs)

What is Chronic Care Management (CCM)?
Chronic Care Management (CCM) is defined as a non-face-to-face care services delivered to Medicare beneficiaries who have multiple (two or more), significant chronic conditions. CCM includes a technology platform that outlines a daily routine for a patient’s medical needs such as follow up appointments, medication refills etc to encourage proactive care and transparency. The technology is complimented by clinical experts who works as extension of the doctors office to help patients.
Does CMS have a specified list of chronic conditions that meet this definition?

As long as you clearly communicate within the care plan that the chronic conditions you are treating post a significant risk of death, acute exacerbatuion or decompensation, or functional decline and will last the expected length of time, the requirement is satisfied. CMS has not specified or otherwise limited the eligible chronic conditions that meet this definition. CMS does have a reference regarding chronic conditions (http://www.ccwdata.org). However, this reference is neither an exhaustive nor definitive list.

What are the requirements needed to initiate CCM services?
Medicare requires you to furnish to the patient an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (also known as a “Welcome to Medicare Visit”), or comprehensive evaluation and management (e&m( visit before billing the CCM service. Oculus Health helps identify the patients who are eligible and assist with scheduling the appointments to maximize CCM enrollment.
What are CCM Scope of Services?

1. Access to care management services 24-hours-a-day, 7-days-a-week, which means providing patients with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.

2. Continuity of care with a designated provider or member of the care team with whom the patient is able to get successive routine appointments.

3. Care management for chronic conditions including: • Systematic assessment of patient’s medical, functional, and psychosocial needs, • System-based approaches to ensure timely receipt of all recommended preventive care services, • Medication reconciliation with review of adherence and potential interactions, • Oversight of patient self-management of medications.

4. Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

5. Management of care transitions between and among health care providers and settings, including the following: • Referrals to other clinicians, • Follow-up after a patient visit to an emergency department, • Follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.

6. Coordination with home and community based clinical service providers as appropriate to support a patient’s psychosocial needs and functional deficits.

7. Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the patient’s care through not only telephone access but also the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.

8. Use of certified electronic health record (EHR) or other health information technology or health information exchange platform that includes an electronic care plan accessible to all providers within the practice, including those who are furnishing care outside of normal business

What should be in a care plan?

The plan of care should typically include, but is not limited to, the following elements:

• Problem list,

• Expected outcome and prognosis,

• Measurable treatment goals,

• Symptom management,

• Planned interventions,

• Medication management,

• Community/social services ordered,

• How the services of agencies and specialists not connected to the practice will be directed/coordinated,

• The individuals responsible for each intervention,

• Requirements for periodic review and, when applicable, revision of the care plan.

Who provides services to patients.

The definition states that “clinical staff” must provide the 20 minutes to qualify. “Clinical staff,” as defined by CPT, “is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.” If the physician or other qualified health care professional (e.g. nurse practitioner or physician assistant) supplies the time, that time may also count toward the 20 minutes.

Oculus Health hires only Certified Medical Assistants and Registered Nurses to their clinical staff. All of our clinical staff work under the guidance of our Chief Medical Officer who is a tripe board certiified physician.

How is Oculus Health different?

There are 3 main differences:

  1. We are the first clinically proven solution
  2. Dedicated and compassionate care managers
  3. CMS Audit guarantee based on shared responsibilities

Quality Patient Care is our #1 Priority.

How does CCM benefit my practice?
 CCM offers several benefits to your practice and organization including:
  • Generates new stream of revenue while improving your practice's reputation
  • Boosts your patient satisfaction levels to new highs by extending your reach through our services = enhanced patient retention.
  • Coaching and activity trackers measure your patients progress over time and improves medication and care plan adherence
  • Test results and personalized recommendations to track care management
  • Your organization will be prepared to tackle value based delivery measures required by current and future medical payers
Does Oculus integrate with my EMR system?
We connect with 720+ EMR systems. Our information sharing approach with EMRs avoids costly, time consuming integration issues.
What are the benefits for my practice?
CCM offers several benefits including
  • New Stream of recurring revenue
  • Boosts your patients satisfaction levels to new highs by extending your reach through our services = enhanced patient retention.
  • Coaching and activity trackers measure your patients progress over time
  • Test results and personalized recommendations to track care management
  • Patients can participate with as little as a telephone
What happens after we sign with Oculus Health for CCM services?
Once a practice signs a contract, we assign an account manager who will coordinate the project. We can enroll a practice in a matter of a day to 30 days depending on their readiness. Entire process can take as little as 1 week to 4 weeks. Once we receive the necessary information, we identify eligible patients, and begin the onboarding process as early as the next day. All in all, the full implementation process takes less than one month.

What services does Oculus Provide?
Patient Services
  1. Oversight of beneficiary self-management medications
  2. Appointment Reminders and Facilitation
  3. Referral management
  4. 24/7 Support staffed by our clinical staff

Care Plan Management

  1. Systematic assessment of beneficiary’s medical, functional, and psychosocial needs
  2. Perform medication reconciliation with review of adherence and potential interactions
  3. Creation of a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment, and an inventory of resources and supports
  4. Electronically share the care plan as appropriate with other practitioners and providers 
  5. Provide beneficiary with a written or electronic copy of care plan and document its provision in the electronic medical record

Care Transitions

  1. Follow-up after: ER visits, hospital discharge, skilled nursing facility, and other inpatient facilities
  2. Facilitate referrals to other providers
  3. Coordinate with home and community based service providers