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Chronic Care Management

Turn ongoing patient care into predictable monthly revenue

OPX Global manages your entire Chronic Care Management program — from patient enrollment to monthly outreach, care plan documentation, and end-of-month billing reports with CPT code support for seamless claim submission — so your practice captures a new revenue stream without adding staff or workload.

Fully managed, end to endNew recurring revenueBetter outcomes between visitsNo added headcount
Financial Impact

The math is simple — and it’s recurring

CCM is one of the few programs that improves care and adds predictable monthly revenue. Drag the slider to see what your panel generates — and what it looks like at scale.

Recurring Revenue
At 100 enrolled patients, your practice nets
$44,400 a year — every year.
Enrolled patients 100 patients
100
Pilot panel Full panel →
Gross Medicare / mo
$6,200
~$62 per patient (99490)
OPX program fee / mo
$2,500
$25 per enrolled patient
Net to your practice / mo
$3,700
~$37 per patient, recurring

Estimates use ~$62/patient/month for CPT 99490 (first 20 minutes of care coordination), minus a $25/patient OPX program fee — about $37 net per patient, every month. Additional reimbursement is available: CPT 99439 adds ~$47/mo per patient for each additional 20-minute increment, and complex patients billing under 99487/99489 generate even higher monthly reimbursement. Actual reimbursement varies by payer, location, and patient complexity; we’ll build a customized projection from your specific panel during a free consultation.

What We Provide

A fully managed CCM program, handled end to end

CCM is one of the most underutilized Medicare reimbursement opportunities available. CMS reimburses practices monthly for coordinating care for patients with two or more chronic conditions — but most practices lack the staff to run it consistently. OPX handles everything, so you capture the revenue and your patients get better care.

Patient Identification & Enrollment

We audit your panel to identify every Medicare beneficiary who qualifies, then manage the full consent and enrollment process — quickly and compliantly.

Dedicated Care Team

Each enrolled patient is assigned a dedicated OPX care coordinator who learns their history, conditions, medications, and goals — so nothing falls through the cracks between visits.

Monthly Patient Outreach

We conduct a minimum of 20 minutes of non-face-to-face care coordination per patient each month — phone check-ins, medication reviews, care-gap follow-up, and specialist coordination.

Care Plan Management

Every enrolled patient has a comprehensive, individualized electronic care plan documenting conditions, medications, goals, and care team contacts — maintained in real time.

Complete Documentation & Time Tracking

Every minute of care coordination is documented in your EHR with time logs that support billing under the appropriate CPT codes — audit-ready at all times.

Billing & Revenue Optimization

We capture all applicable CCM codes each month — including CPT 99490, 99439, 99487, and 99489 — ensuring you’re reimbursed for every eligible minute.

Provider Staff Education

Your dedicated Account Manager provides education to clinical staff on face-to-face patient enrollment, qualifying criteria, and billing the G0506 G-code — an additional revenue opportunity available to eligible patients.

Eligibility

Is your practice a good fit for CCM?

CCM is available for Medicare and Medicare Advantage patients who meet specific criteria. Your practice is likely a strong candidate if:

Bottom line: if your practice sees Medicare patients with chronic conditions, you almost certainly have eligible patients who aren’t yet enrolled — and revenue you’re not yet collecting.
Why OPX

Why practices choose OPX

Expert CCM Strategists

Our team understands both the clinical and compliance dimensions of CCM — CMS guidelines, billing requirements, and what makes a program sustainable long term.

  • Deep knowledge of CCM codes & CMS rules
  • Dedicated program manager for every practice

HIPAA Compliant

All outreach and care coordination is conducted over secure, HIPAA-compliant channels, with audit-ready documentation.

  • 100% HIPAA-certified care coordinators
  • Secure communication & documented access controls

Pre-Trained & Ready

All OPX CCM staff are US-based, experienced Certified Medical Assistants (CMAs) — pre-trained in chronic disease management, EHR documentation, and CCM compliance, and ready to begin engaging your patients from day one.

  • US-based, experienced Certified Medical Assistants (CMAs)
  • Trained on major EHR platforms
  • Ongoing QA reviews for outreach & documentation

Performance-Driven

We hold ourselves accountable to the metrics that matter — enrollment, outreach completion, documentation accuracy, and revenue captured.

  • Transparent monthly performance reporting
  • Focused on enrollment & reimbursement capture
OPX vs. In-House

Most practices have tried CCM internally — and found it unsustainable

CategoryIn-House CCM AttemptOPX Global CCM
Monthly Outreach Inconsistent — depends on staff availability Consistent — dedicated coordinators every month
Care Plans Often incomplete or outdated Maintained and updated in real time
CPT Code Capture Frequently missed or undercoded Fully optimized across all applicable codes
Compliance & Audit Self-managed, high risk Audit-ready documentation at all times
Staff Burden High — pulls clinical staff from other duties Zero — fully managed by OPX
Program Fee Hidden costs: staff time, training, turnover $25 per completed 99490 — transparent & predictable
Scalability Limited by internal capacity Scales with your enrolled patient volume
Launch

Launching your CCM program takes four simple steps

1

We Identify Your Eligible Patients

We review your panel, identify every qualifying Medicare beneficiary, and show you exactly what that means for your monthly revenue potential.

2

We Enroll & Consent Your Patients

Our team handles outreach, consent documentation, and enrollment at a pace that fits your practice and keeps patients informed.

3

We Build & Launch the Program

We create individualized care plans, assign dedicated coordinators, and establish documentation workflows in your EHR.

4

Ongoing Coordination & Billing

Each month: outreach completed, care plans updated, time documented, all CPT codes captured — with monthly revenue reporting.

FAQ

Chronic Care Management questions, answered

What chronic conditions qualify a patient for CCM?
Medicare defines qualifying conditions broadly — common examples include diabetes, hypertension, heart failure, COPD, chronic kidney disease, depression, arthritis, and obesity. Patients must have two or more documented conditions expected to last at least 12 months.
Do patients need to give consent to participate?
Yes. CMS requires written or verbal consent before CCM services begin. OPX handles the entire consent process on your behalf, documented correctly and compliantly.
Do your care coordinators work in our EHR?
Yes. Our coordinators document care plans and time logs directly in your EHR so everything is visible to your clinical team and audit-ready.
What does OPX charge, and how does billing work?
OPX charges $25 per completed CCM encounter resulting in a billable CPT 99490. You bill Medicare directly and receive the full reimbursement (~$62/patient/month). OPX invoices the $25 fee separately, leaving roughly $37 net per patient per month. No setup fees or long-term contracts.
What happens if a patient doesn’t answer their monthly call?
Our coordinators make multiple documented outreach attempts each month. If a patient is consistently unreachable, your account manager flags them for review and works with your team on re-engagement or appropriate disenrollment.
How quickly can we launch the program?
Most practices are up and running within 2–4 weeks. Your dedicated account manager handles all setup, EHR coordination, and patient outreach logistics.

Your eligible patients are already in your panel

Let OPX Global identify your eligible patients, estimate your monthly net revenue, and launch your CCM program — at no added burden to your team.