How the money actually works.
Between-visit care management is a paid program under Medicare and many commercial plans. Your practice bills it. We explain the mechanism here because most vendors either hide it or turn it into a projection.
How a billable month adds up.
These programs are built on time: a defined number of minutes of clinical staff work in a calendar month. Reach the threshold and the month counts. Fall short and it does not, however useful the work was.
0 of 20 minutes
Add an activity and watch the month fill.
Clinical staff time per calendar month. Twenty minutes is the threshold for base chronic care management and for behavioral health integration; complex chronic care management is sixty. The minutes on each activity are illustrative. The thresholds are not. Reaching a threshold is also not the whole test — eligibility, consent, practitioner oversight and documentation all still apply. No rate, no revenue and no projection for your practice.
Your practice bills. We never do.
Anuvra holds no Medicare provider number, submits no claim and receives no payment from any payer. The revenue from a care-management program goes to your practice, because your practice is the billing entity and your practitioner carries the supervision the program requires.
We are paid by your practice, under a services agreement, for clinical capacity and documentation. That is the whole of our financial relationship with the program.
What these programs pay for.
Medicare's care-management programs — chronic care management, principal care management, behavioral health integration and collaborative care among them — pay a practice a monthly amount per enrolled patient when four conditions are met.
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The patient must qualify and must consent
Each program defines who is eligible — chronic care management, for example, requires two or more chronic conditions expected to last at least twelve months. The patient is told about the program, including any cost-sharing, and agrees to be enrolled.
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Qualifying clinical staff time is spent in the calendar month
A defined number of minutes of clinical staff work in the month, spent on activities the program recognizes.
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A practitioner directs and oversees the work
The billing practitioner supervises the clinical staff time, reviews and approves the care plan, and remains available. CMS is explicit that this oversight cannot be delegated or subcontracted. It is your practitioner's, and it is the reason the arrangement is lawful.
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The work is documented well enough to survive review
Time, activity, escalation and the care plan itself are recorded in the practice's record. Care-management billing is under active federal audit scrutiny, and the documentation is what the reviewer reads.
Four variables, and only one of them is the rate.
Practices often ask what a program is worth. The honest answer is that it is the product of four things, three of which are facts about your practice rather than facts about Medicare.
01How many patients qualify
A function of your panel, not of the program. This is usually knowable from your own data before anyone is contacted.
02How many of those enroll
Patients must be told about the program and agree to it. Enrollment rates vary widely by population and by how the conversation is handled.
03How many enrolled months reach the threshold
The variable most often assumed away. A patient who cannot be reached in a month is an enrolled patient with no billable month.
04The rate your payer sets
Set by CMS or the plan, adjusted for your locality, and revised annually. The one variable neither you nor we influence.
Rates and program rules change every year through the Medicare Physician Fee Schedule, and commercial coverage varies by plan. Current figures, eligibility rules and cost-sharing should be confirmed with your billing advisor or payer, not taken from a vendor's website.
A fixed fee for the work, not a cut of what it collects.
Anuvra is never paid a percentage of your collections. Full-service care-management vendors in this market commonly are, and it is the most consequential difference between the two models.
When a vendor's income rises with the number of billable months, the vendor has an interest in enrollment volume and in months crossing the time threshold. Your practice carries the compliance exposure for both, because your practice is the entity that billed.
Our fee is set from the agreed patient population, clinical capacity, workflow complexity and scope, and does not move when a month becomes billable.
Program support, not billing advice.
Anuvra provides clinical capacity and documents the work performed. Coding, claim submission and every payer decision belong to your practice, and we do not advise on them. Where our documentation supports a program your practice bills, that is a consequence of the work being done properly, not the service itself.
We will not model your revenue.
You can find vendors who will put a number on your practice before they have met a patient. We do not, and the reason is not modesty.
A projection built on assumed enrollment and assumed threshold rates is a forecast of your behaviour dressed up as a forecast of Medicare's.
What we can do is work the arithmetic with you against your own panel and your own data, and then measure the real rates during a defined pilot. After a pilot you have your numbers instead of ours.
Nothing on this page is billing, coding, legal or financial advice, and nothing on it guarantees reimbursement, coverage, claim approval or any financial result. See our Legal Disclaimer.
Worth fifteen minutes?
Start with a short conversation about your patient population, workflow and current staffing pressure.