Unlock Recurring Medicare Revenue While Elevating Patient Care
Most primary care clinics have hundreds of CCM-eligible patients — yet only a fraction are consistently enrolled and managed.
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Chronic Care Management (CCM) is a Medicare-covered benefit for patients with two or more chronic conditions expected to last at least 12 months. When executed properly, CCM improves patient continuity while generating predictable monthly reimbursement.
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The challenge isn’t eligibility. It’s structured execution.
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Eleos Virtual Healthcare Solutions deploys dedicated Virtual Healthcare Associates (VHAs) who operationalize CCM inside your existing workflows — compliantly, consistently, and at scale.
Why CCM Is a Strategic Opportunity for Your Clinic
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Improve Patient Outcomes - Structured monthly support helps identify issues early, reinforce medication adherence, coordinate care, and reduce avoidable escalations.
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Capture Recurring Medicare Revenue - CCM converts care coordination your clinic is already attempting into compliant, billable monthly reimbursement.
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Protect Provider Time - Your VHA manages outreach, documentation, care plan updates, and coordination — allowing providers to focus on clinical oversight and decision-making.
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Scale Without Expanding Headcount - Deploy CCM support virtually — no additional in-office staff required.
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Think of them as your clinic’s dedicated care coordinator—helping patients stay proactive in their health while reducing the burden on providers and onsite staff.
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​What CCM Requires (And What We Execute) ​
CCM services are delivered outside traditional office visits and must meet Medicare documentation and time requirements.
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Core CCM Service Elements
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Development and ongoing maintenance of a comprehensive electronic care plan
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Monthly non-face-to-face patient outreach
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Medication reconciliation and adherence review
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Coordination with specialists and other providers
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Monitoring of chronic condition status and care gaps
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Documentation and compliant time tracking
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Communication updates to providers and care team
This ensures your clinic delivers structured, compliant care management — not inconsistent follow-up calls
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​​​​​​​Optional Turnkey CCM Enrollment & Compliance Support ​​
Execution begins with enrollment.
Eleos provides a structured, turnkey enrollment model to help your clinic activate eligible patients quickly and compliantly.
Your CCM Specialist:
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Conducts outreach to patients identified by your clinic as CCM eligible
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Educates patients on CCM services and benefits
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Secures and documents required patient consent
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Builds the initial comprehensive care plan
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Transitions patients into recurring monthly management
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Manages annual re-enrollment and consent renewal to prevent revenue gaps
Without structured enrollment and annual tracking, clinics often lose eligible patients — and recurring revenue.
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*Turnkey enrollment and annual re-enrollment services may involve an additional fee depending on panel size and enrollment goals.
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Medicare Reimbursement: The Financial Impact
CCM is reimbursed under the Medicare Physician Fee Schedule.
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*Rates vary by locality and payer mix. Source: ThoroughCare​​​​​
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What This Means Financially
Using base CCM (99490 only):
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​Add-on time and complex CCM increase this opportunity further.
Many clinics are sitting on six-figure recurring revenue simply because they lack structured execution.
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Execution — not eligibility — determines performance.
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Bilingual, College-Educated Medical Doctors—Providing High-Quality Support at a Cost-Effective, All-Inclusive Rate Covering Taxes, Benefits, PTO, and More.
Who This Is Ideal For
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Primary care clinics with 100+ eligible Medicare patients
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Practices participating in Value-Based Care contracts
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Clinics that attempted CCM but struggled with consistent execution
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Groups seeking predictable recurring Medicare revenue
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Compliance & Oversight
CCM services are delivered under the supervision of the billing practitioner.
The provider retains clinical oversight and medical decision-making authority.
The VHA executes operational components — including outreach, documentation, care plan maintenance, and time tracking — under general supervision consistent with CMS guidelines
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Turn Eligibility Into Execution
If your clinic has eligible Medicare patients but no structured CCM engine, you are leaving both patient continuity and recurring revenue on the table.
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Eleos provides the staffing, workflow integration, and operational discipline to transform CCM into a dependable clinical and financial asset.
