Achieve the goals of Triple Aim

  • Enhance patient experience
  • Lower healthcare costs
  • Improve health outcomes

At DrCatalyst, we act as an extension of your team.
We treat your patients like we treat our patients. DrCatalyst's CCM program fills the gap between office visits with one-on-one, personalized interactions to help patients better manage their conditions


Maximize Incentives

CMS places significant weight on CCM for your MIPS score. With DrCatalyst’s CCM program, our experts will help you succeed with CCM so you can achieve optimal and consistent MACRA compliance—which means maximum incentives and zero penalties.

generate income

Generate More Income

Under the CCM program authorized by CMS, you can bill $43 - $142 per month, per Medicare patient with two or more chronic conditions who receive at least 20 minutes of chronic care activity associated with non-face-to-face care coordination services.


Automate Your Workflow

No need to disrupt your current processes. You’ll receive ready-made documentation and regular reports that allow you to easily bill for chronic care services. Your patients also receive regular check-in calls to monitor their health, satisfaction, and engagement.


Benefits for the Providers

  • Improve Patient Outcomes
  • Increase Practice Revenue
  • Improve your MACRA/MIPS Scorecard
  • Decrease Administrative Workloads
  • Enhance Patient Satisfaction

Benefits for the Patients

  • 24/7 Access to Healthcare Support
  • Personalize Care Plans
  • Lower Healthcare Expenses
  • Support to Reinforce Healthy Habits
  • More Engagement = Better Outcomes
patient-engagement (1)


Chronic disease is a formidable foe.

One of the primary reasons CCM is so important is that it helps all stake holders in healthcare — patients, physicians, and payers — deal with the serious and costly problem of chronic disease.



What is required for CCM?

Detailed list of requirements from CMS

2 or more chronic conditions Must use a certified EHR Technology 24/7 access to care management services
Serious health risk or at risk of death 20 minutes per patient per month Comprehensive patient-centered care plan
Must consent to the CCM Service Documented time spent per patient Care plan available 24/7 to entire staff
May have a co-pay Monthly reports and summary of CCM Care plan shared with EMR and other providers


Chronic Care Staffing closes the gaps in care for your patients and opens the door to additional revenue for you.

A comprehensive set of chronic care management services:




  • Increased Patient Education / Awareness
  • Identifying Patients in Need of Their Annual Wellness Visit (AWV)
  • Assisting with Medication Refills / Reconciliation
  • Assisting with Verbal Enrollment Maximizing CCM Patient Participation
  • Documenting and Reporting Change in Patient Health Status
  • Referral Coordination
  • Transition of Care Notice to Provider

Exciting news about CCM Expansion

  • Medicare Advantage, Medicaid, and Commercial payers are actively entering the market.
  • Remote enrollment is now allowed
  • New code 99487, 99489, and G0506 are now available for CCM
  • CCM is now available for RHC and FQHC Practices

Why choose DrCatalyst for your CCM services?


1 Patient Qualification

Do you have Medicare beneficiaries with two or more chronic conditions expected to last the next 12 months? Our trained remote staff will identify patients from your EHR who are eligible to participate in the Chronic Care Management program.

Healthcare partners in your area can assist you in sorting out a list of patients who are eligible for CCM services.

2 Patient Outreach

We will reach out to your eligible CCM patients on your behalf to educate them about the benefits of the program, how it works, and, if necessary, provide assistance on scheduling their next office visit to obtain enrollment consent.

3 Staff Training

To ensure a successful CCM program launch for your practice and help you furnish a successful CCM service, we train your staff on the overall program, how to identify eligible CCM patients, and how to engage your current patients.

4 1-on-1 Patient Engagement

Our trained staff will engage with your qualified patients for at least 20 minutes every month to review their care plan and progress toward the patient’s individual healthcare goals. Rest assured our team serves as an extension of your practice with the promise of delivering the same high quality patient engagement you and your staff adhere to!

5 Comprehensive Care Plan Development

Through a comprehensive assessment of the patient’s medical, functional, and psychosocial needs, our trained staff will create a comprehensive care plan for each patient. It serves as a road map for patients to follow and track their progress.

6 Management and Monitoring CCM Patients Care

We provide a fluid digital care plan you can utilize at all points of care. The comprehensive care plan for each patient is created, established, implemented, revised and monitored throughout the program. It is an easy way for providers to track the patient and their progress.

7 Documentation

Our remote staff will document all CCM activities directly in the patient’s medical record (Beneficiary Consent, detailed account of the non-face-to-face services provided, and the Comprehensive Care Plan) required by Medicare.

8 Reports Auditing

Don’t miss out on lost revenue. With CCM, you can only bill in months with activity, so it is critical to ensure proper reporting. Our staff provides an auditable report at the end of each month so you can easily bill the 99490 and other codes for your CCM patients.

9 24/7 Availability

Due to its non-face-to-face nature of patient care, it is vital in the CCM program to provide a 24/7 care management access for patients. In addition to a patient portal where patients can view health information such as recent doctor visits and medications, DrCatalyst's CCM program offers patients 24/7 telephone service.

DrCatalyst's CCM Process


  • Week 1
    • Verify EMR Compliance
    • Draft Implementation
    • Agree on Scope
    • Draft Agreement
  • Week 2
    Workflow Analysis
    • Hold Workflow Analysis
    • Provide Patient Materials
    • Analyze Patient Data
    • Create Opportunity List
    • Obtain RN EMR Access
    • Train RN on EMR
    • Finalize Workflow
  • Week 3
    Patient Enrollment
    • Contact Patients Not Enrolled
    • Obtain Patient Consent
    • Create Care Plans
    • Document all Information in EMR
  • Week 4
    Care Management
    • Document all Information in EMR
    • Manage Transitions
    • Monthly 20-minute Follow-up
    • Monthly Billing Reports
    • Send Monthly Summary

Frequently Asked Questions

1. What are the CCM requirements?

Chronic Care Management services require a minimum of 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional per calendar month with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

2. Will it cost anything for my patients?

If they are Medicare Part B patients with no secondary coverage, yes. It will cost them $8/month.

If they have a supplemental coverage, there is no additional cost.

3. What are DrCatalyst’s access to care and care continuity?

DrCatalyst’s CCM service provides your CCM patients with 24-hour-a-day, 7-day-a-week (24/7) telephone access to our qualified clinical staff. This provides your patients with the means to make contact with a healthcare professional any time or day of the week.

Patients will also have 24/7 access to an online patient portal where they can view their care plan, medications, and communicate through secure and direct messaging with their physician.

4. Does DrCatalyst's licensed clinical staff follow Medicare’s physician supervision requirements?

Absolutely. CMS permits clinical staff to provide CCM services “incident to” the services of the billing physician (or appropriate practitioner). This allows our licensed clinical staff to provide CCM services on your behalf rather than under the direct supervision of a physician.

5. What are the prerequisites of a CCM service?

For new patients or patients not seen within one year prior to the start of CCM, Medicare requires the initiation of CCM services during a face-to-face visit with the billing provider: Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or Evaluation and Management Visit (E/M).

6. How does the 20-minute patient care time work?

Our remote staff will reach out to your qualified patients to schedule a monthly 20-minute call where we discuss their healthcare goals. During the call we talk through their progress and ensure that they are complying to the medications, diet, and routine exercises as prescribed by their doctors based on their individual care plan.

7. Who can provide CCM?

  • Physicians (of any specialty)
  • Licensed Clinical Staff Members
  • Advanced Practice Registered Nurses
  • Physician Assistants
  • Registered Nurses
  • Licensed Clinical Social Workers
  • Licensed Practical Nurses
  • Clinical Nurse Specialists
  • Clinical Pharmacists
  • Certified Medical Assistants

8. How many providers can bill for CCM?

Per CMS, only one provider can bill a CCM service per patient per month.

9. What codes can’t overlap with CCM services?

  • Certain ESRD codes 90951-90970
  • Home Healthcare Supervision code G0181
  • Hospice Care Supervision code G0182
  • Transitional Care Management codes 99495 and 99496

10. Why choose DrCatalyst for your CCM program?

DrCatalyst is a trusted and proven remote staffing partner. Our entire model is based on our staff of dedicated healthcare professionals working as an extension of your team. You can rest assured your patients will receive the supplemental care they need and you’ll receive peace of mind with detailed reporting and documentation to back it up!

11. Is DrCatalyst’s remote staff HIPAA certified?

Yes. Our remote staff team goes through thorough HIPAA-compliance training and are required to maintain compliance with HIPAA training refresher courses every year.

Ready to Succeed in CCM?

Let's get started! Find the plan that's right for your practice and your patients



one time fee

$3.50 per billed patient per month

IMS CCM Module and Setup Procedure

Consulting Available

Long-Term Access for CCM Queries for 2018-2019



Dedicated Nurse / MA

IMS CCM Module and Setup

Patient Consent Signature

Dedicated Care Manager

24 x 7 Coverage

Care Plan Creation and Monthly Revision

Disease-Based Protocols

Complete Billing Cycle Management

Improved Practice Appointments

Monthly Performance Reports

Online Portal Management