RHCs Beware: “Outsourced CCM Vendors” Compliance Nightmare

August 23, 2022

Chronic Care Management (CCM) outsourcing companies are causing patient frustration, less ROI from adding internal hires, and CMS compliance issues with no easy way to cancel their contract.

Over the past year or so we have learned about specific CCM Outsourcing Vendors that are engaging in murky practices to say the least. In one case a Rural Health Center (RHC) customer of ours is also working with a CCM Outsource Vendor for a specific segment of the patient outreach. They inform of the following:

“Our patients really didn’t understand that they were signing up for a program with the [CCM outsourced call center.] We are unhappy with the results, but our clinics are stuck with the contract for 3 years.”

They and other rural health clinics nationwide were tempted by the “no staff required to receive reimbursement” promises of many Outsourced CCM Companies.

To be clear, CCM is a legitimate program by the Centers of Medicare and Medicaid Management (CMS) that offers improved patient outcomes, value-based care incentives, increased health equity with connections to community resources and more. Importantly, CCM programs represent a compelling onramp for RHCs to embrace value-based contracts. Read about the CCM benefits for RHCs here

Due to increased reimbursement in 2022, many service companies have started offering to run CCM programs with call centers. The purpose of CCM is not just transactional-like phone calls, it is offering the patient a deep understanding of their health concerns, driven by a comprehensive coordinated, evidence-based plan based on their chronic condition. This includes professional, patient-centric follow up. Some key value drivers to consider before opting to select a call center-based model for your CCM program:

Beware–Compliance Risks

Outsourced CCM Companies often operate by having “health coaches” and not licensed RNs, LVNs or at least MAs asking clinical questions of your patient population. They claim their process is provider initiated by sending large lists of patients to your providers that they “ok” without explaining the federal rule in its entirety. CCM requires an initiating visit and “If a provider doesn’t discuss CCM during (the initiating visit), it can’t count as an initiating visit.”

In the call center/outsourced model, we are hearing that the non-clinical staff may ask clinical and health equity questions of your patient population then report these back to your clinical staff in terms that might be inappropriate or negligent to the severity of the patients’ condition.

A comprehensive care plan is also a CCM requirement. This is “out of scope” for anyone without a Registered Nurse (RN) credential.  Some of the worst companies will use templated goals and educational sheets for the conditions they asked the patient about, hardly qualifying as a care plan. The templates are “boiler plate” with goals related to the patient’s chronic conditions.

A Chief Nursing Officer stated “All of our patients with hypertension had the same goal: to quit smoking, but many of them weren’t even smokers to begin with. I now have sincere concerns if we get audited.”

Certain outsourced CCM companies will send a report at the end of the month with what needs to be done, a dangerous three to four weeks after a serious clinical discovery was found. It is important to recall that eligible CCM patients are required to have multiple chronic conditions and often comorbidities, therefore the best of care should be utilized. Consider these RHCs’ approach.

Actually Outsourced?

Often Outsourced CCM Vendors will use staff without medical backgrounds to ask your patients clinical and health equity questions. After doing this, their staff will assign tasks or “notifications” to your staff to complete. Many clinics have mentioned they are forced to hire additional staff to meet the demands of the “outsourced company,” ultimately forcing your clinic staff to meet the requirements of the program internally without the benefit of full reimbursement.  The additional staffing remarkably alters the ROI the vendor’s claim with an unjust percentage of the additional revenue.

Loss of Patient Loyalty

“Our patients and their families feel like they were scammed into program they didn’t fully understand.”

As patient consent is an absolute requirement for the Chronic Care Management program, many rural health clinics are inundated with patients calling in confused about their participation. Additionally, when internal staff is looking at the patient record, they will see many different “health coaches” reaching out to the patient without consistency in the staff talking to the patients and scheduling tasks for the clinic staff to perform. “Our patients do not even have the same individual communicating with them” reiterates an RHC CEO. The most successful programs have nurse care coordinators that build authentic one-on-one relationships with their patients.

Contracts: Read Between the Lines

Extreme, ethically questionable withdrawal fees. Long contract lengths. If many patients leave the program at once, it will be the clinic’s fault. These are some of the contractual obligations healthcare organizations are held to by the CCM outsourced companies, even if their patients are displeased with the services (or lack thereof) provided. 

Summary of Questions to Ask Potential CCM Vendor:

  1. If we want to cancel our subscription, what would that entail?
  2. What are the credentials of the staff who will be handling my patient’s clinical information?
  3. If something needs to be done on behalf of the patient (pre-auth, connection to resources, labs, med rec, etc.), what does that workflow look like?
  4. Will your staff members be creating care plans for our patients? If so, will you use templates? If not, will we be expected to create the care plan?
  5. Will our patients have consistency of staff supporting them in CCM?

A Better Option

CrossTx commits ongoing investment in technology and services to support care coordination programs nationwide. Be very careful with any Outsourced CCM Vendors, consider asking the tough questions based on the issues raised herein before signing any contract.  More information on this topic is forthcoming from CrossTx. Learn more here.

Chandra Donnell

VP Client Success


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