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Chronic Care Management
Nurse providing chronic care

What Is Chronic Care Management?

Chronic Care Management (CCM) is a proactive, Medicare-approved service designed to support patients with two or more chronic conditions—such as diabetes, hypertension, COPD, arthritis, or heart disease. These individuals often require frequent communication, medication adjustments, and consistent engagement to prevent complications and maintain long-term health.

Through monthly check-ins by licensed clinical staff, CCM helps patients stay on track with their treatment plans. This includes reviewing symptoms, ensuring medication compliance, providing lifestyle coaching, and reinforcing preventative care—all between in-office visits.

Chronic care services reduce ER visits and hospitalizations while improving patient outcomes and satisfaction. For providers, CCM offers a powerful way to enhance care quality and generate ongoing revenue—without burdening internal staff or disrupting workflow.

OnPoint advisor and 24Our Care team

Why OnPoint Partners with 24Our Care®

At OnPoint, we collaborate with 24Our Care® because of their trusted and proven ability to deliver Medicare care coordination services at scale. Their team of licensed U.S.-based clinicians provides Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), and Annual Wellness Visits (AWV) in full compliance with CMS requirements.

By combining OnPoint’s consultative expertise with 24Our Care’s clinical infrastructure, we help practices implement a complete turnkey solution that improves patient care, drives engagement, and increases recurring revenue. There’s no added staffing, software, or disruption to your daily operations—just better care delivered efficiently and effectively.

This partnership ensures that our clients receive a service model that is scalable, compliant, and designed to reflect the high standards of their practice while delivering meaningful outcomes to patients.

Clinical Outcomes of CCM

Clinical Outcomes of Chronic Care Management

Chronic Care Management (CCM) services are proven to enhance patient outcomes across a wide range of clinical indicators. Multi-center research studies, Medicare claims analysis, and independent benchmarks have consistently shown that CCM participation leads to measurable improvements in condition control, preventive screenings, and reduced acute care usage.

Frequently Asked Questions
Chronic Care Management (CCM) for Medical Providers

What does 24Our Care® provide to help implement CCM in my practice?

24Our Care® offers a complete turnkey solution, including clinical staff, care coordination technology, compliance documentation, and regular reporting. They work under general supervision and do not require additional staff or workflow disruption.

How is the service billed? Do I need to handle billing internally?

24Our Care® provides documentation for CMS-compliant time tracking and care logs. Most providers bill CCM services using standard CMS CPT codes (99490, 99439, etc.), and 24Our Care® can assist your billing team with integration.

Who communicates with my patients?

All patient outreach is conducted by licensed U.S.-based clinical staff from 24Our Care®. They act as an extension of your practice and maintain regular communication with your patients, providing care plan updates and wellness checks.

Do I have to install any new software?

No. 24Our Care® uses its own HIPAA-compliant technology platform and integrates securely with your EHR via standard protocols. There is no software for your team to learn or install.

What types of practices benefit from outsourcing CCM?

Primary care, internal medicine, cardiology, endocrinology, and geriatrics all benefit from CCM services. Busy practices looking to expand care delivery without additional staffing are ideal candidates.

What happens if a patient opts out or discontinues participation?

If a patient chooses to opt out, they will no longer receive CCM services. 24Our Care® tracks participation status and updates your office to maintain accurate billing and compliance records.

What are the time and supervision requirements?

CMS requires at least 20 minutes of non-face-to-face care coordination per calendar month, documented in real time. Services must be provided under the general supervision of the billing provider.

What compliance standards are followed?

24Our Care® adheres to all CMS documentation and reporting standards, including consent logs, care plans, monthly time logs, and system audits. They undergo regular internal reviews and maintain full HIPAA compliance.

How much training is required for my staff?

Minimal training is needed. 24Our Care® handles all patient interactions and documentation. Your staff only needs to understand how to approve participation and review care summaries.

How long does it take to launch the program?

Most practices can go live within 2–4 weeks. 24Our Care® provides onboarding, EHR integration, and patient enrollment workflows to accelerate implementation.

Can we review patient outcomes and program performance?

Yes. You’ll receive regular reports on patient engagement, condition metrics, and compliance summaries. These reports help demonstrate clinical value and support QPP/MIPS metrics.

Can I still bill for in-office visits and other services?

Absolutely. CCM billing is separate from E/M office visits, Annual Wellness Visits, and many preventive screenings. You can provide face-to-face care as usual while the CCM program enhances patient follow-up between visits.
Disclaimer: This FAQ is intended for healthcare providers evaluating Chronic Care Management services through 24Our Care®. Information is based on current CMS regulations and standard industry practices. OnPoint Fast LLC is not a clinical service provider and offers this content for informational purposes only.

Still have questions?

If you're considering adding a CCM program or working with 24Our Care®, click below to email us directly. We’ll respond promptly and connect you with the right team.

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Helpful Documents

OnPoint Chronic Care White Paper - 4pg.pdf