Advanced Primary Care Management (APCM): What Providers Need to Know?

Primary care is a thing of the past, often addressed as an inefficient care model that doesn’t provide desirable results. In the United States, where 6 in 10 adults live with at least one chronic disease, the traditional model is no longer sufficient to deliver high-quality care and patient outcomes. As a result, a value-based, proactive, and data-driven model has  emerged—the  Advanced Primary Care Management model.

In this blog, we’ll dig into the details of the Advanced Primary Care Management, including its benefits, implementation, billing codes, and everything else. We’ll explore what the APCM model really is and how health providers can implement it into their clinics and increase revenue.

So, what is Advanced Primary Care Management? 

Advanced Primary Care Management (APCM) is a patient-centric healthcare delivery model that goes beyond traditional care. By integrating direct primary care with care coordination and chronic disease management, it forms a cohesive care system for patients.

Advanced Primary Care Management (APCM) is a structured care model designed to provide preventive and coordinated care to patients dealing with chronic issues. Consider it a transformative evolution of the conventional system that promotes preventive, continuous, and coordinated care. The model integrates technologies such as Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) along with Artificial Intelligence to small clinics, to make them efficient.

But before we dive into the APCM concept, let’s discover what primary care is. Primary care refers to first-contact care, which is accessible, continuous, and comprehensive. It serves as the foundation for APCM by inculcating technology, data, and team-based care to improve patient results while reducing costs. The emphasis of the primary care model lies in

• Whole person care
• Team-based coordination
• Proactive health management
• Technological monitoring and patient engagement

Practices that have adopted the APCM models witnessed a 35% reduction in hospitalizations and a significant enhancement in patient satisfaction. Take, for example, the Comprehensive Primary Care Plus (CPC+) initiative by CMS, which highlighted the role of enhanced primary care coordination in measurable improvements in cost efficiency and care quality.

How APCM is different from Traditional Chronic Management? 

Traditional chronic care management focuses on tackling existing chronic conditions through in-person regular visits. Advanced Primary Care Management, on the contrary, virtually takes a comprehensive approach, including prevention, management, and overall patient wellness. Here’s a table explaining the differences.

The Advanced Primary Care Model (APCM) offers stable care and complex management, varying from patient to patient. It caters to patients with diverse needs and bills accordingly. Traditional care cannot address patients with multiple chronic diseases or high complexity ailments, but APCM can.

Additionally, Advanced Primary Care Model (APCM) allows you to bill for codes that highlight the intensity of care required. An important thing to note is that only primary care providers can bill for APCM. This encourages team involvement, leading to well-rounded care for patients.

Benefits of the Primary Care Model for Medicare Providers 

Advanced Primary Care Management is extremely advantageous for Medicare providers. By offering value-based care frameworks (opposed to the volume-driven traditional models), it focuses on improving patient outcomes while ensuring financial sustainability.

Here are the key benefits of the Advanced Primary Care model:–

• Enhanced Care Coordination = Reduced Hospitalizations

Care under the APCM model is initiative-taking and team based. This enables providers to actively monitor patient vitals, identify health issues in the initial stages, and intervene at the right time. Consequently, the chances of emergency visits, hospital admissions, and readmissions within 30 days are reduced.

Tip- As a Medicare Shared Savings Program participant, you can use advanced primary care strategies to reduce total care costs and ensure better chronic care management. 

• Improved Patient Satisfaction

Value-based programs such as MACRA and MIPS, which fall under APCM, work to enhance patient satisfaction and experience scores. APCM emphasises personalized care, detailed consultations, and 24/7 care access. This leads to enhanced care and higher Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores.

Better ratings can help increase reimbursements, improve your reputation, and beat competition in the Medicare Advantage network.

• Access to Shared Savings and APMs

APCM allows providers to embed Alternative Payment Models (APMs) and shared savings programs under the CMS innovation initiatives. As a provider, you can showcase improved outcomes and reduced costs and retain a portion of the savings. Applicable models include-

• • Comprehensive Primary Care Plus (CPC+)
  • Primary Care First
  • Accountable Care Organizations (ACOs)

Bonus- Partnering with these programs offers you financial support during the transition period.

• Eligibility for Strategic CMS Initiatives

APCM providers are eligible for national CMS programs such as

CPC+ (Comprehensive Primary Care Plus)- a program that offers care management fees, performance-based incentives, and enhanced payments to providers.

Primary Care First- a program that prioritizes innovation in care delivery for high-need Medicare patients.

Participation in these programs offers you infrastructure support, technical help, and bonus payments, helping your small practice grow and sustain.

How Advanced Primary Care Increases Revenue for Providers? 

Implementing the Advanced Primary Care Model in your clinic is an upgrade and a business decision that contributes to sustainable revenue growth. Proactive adoption of the APCM can allow you to tap into varied revenue streams while enhancing the operational and financial rewards of the pre-existing ones. Here’s how the APC model drives financial benefits-

1. Revenue from CCM Billing Codes 

Chronic Care Management billing codes allow providers to bill and get reimbursed for providing virtual care to Medicare patients with two or more chronic diseases. APCM allows providers to integrate these services into routine work, generating more revenue.

Billing codes like CPT 99490, 99439, and 99487 enable providers to bill monthly for each patient. The revenue generated by a single patient can go up to $75 per month in additional revenue.

By scaling APCM across hundreds of patients, CCM can help you build a substantial revenue stream.

2. Remote Patient Monitoring (RPM) Reimbursements 

RPM allows practices to monitor vital signs and key health metrics of patients virtually. Using connected devices like glucometers or blood pressure monitors, providers can track vitals in real-time and prevent complications beforehand. This accounts for exclusive reimbursement opportunities for providers.

• • CPT 99457 and 99458 allow monthly reimbursements for 20 minutes or more of remote care (single interaction).
  • CPT 99453 and 99454 allow billing for device setup and data transmission.
  • With RPM, providers can generate $100- $150 monthly per patient.

This model promotes remote patient care, reduces workload, and improves patient engagement while boosting revenue.

3. Transitional Care Management Payments (TCM) 

TCM services are for patients in the period after their hospital discharge. This is the period when they are at a high risk for complications or readmission.

CPT 99495 and 99496 allow providers to provide care, bill, and receive up to $240 per patient within 7-14 days post-discharge. APC empowers providers to contact and support patients through medication counselling and follow-up planning. This revenue aligns with CMS’s goal of reducing readmissions and is also clinically justified.

4. Shared Savings in Accountable Care Organizations (ACOs) 

Practicing working with the APC model are eligible to participate in value-based care programs such as ACOs. Providers who offer lower healthcare costs while improving patient outcomes can share in the savings generated.

ACOs evaluate metrics like hospital utilization, patient satisfaction, and total care cost. Based on the analysis, Medicare or commercial payers pay year-end bonus payments to high-performing providers. Participation in programs like ACO REACH or Next Gen ACO programs can further increase these benefits. Improvement in the quality of care can thus help you enhance your finances.

5. Reduced Overhead Costs with Telehealth and Automation 

By promoting automation and incorporating telehealth into your clinic, you can reduce administrative burden and increase income. With the help of automation, your clinic can offer better care to more patients with less manpower.

Telehealth improves patient results and engagement and ensures long-time relationship with patients. It also cuts down unnecessary in-person visits, saving time and facility resources. Providers can also outsource non-clinical parts of care management, such as documentation, check-ins, etc, saving time and costs. Overall, this leads to additional revenue streams with enhanced efficiency.

Also Read- Advanced Primary Care Management (APCM) Use Cases in Remote Healthcare

Who Can Provide APCM? 

While APCM is structured to be widely accessible, there is a limit on who can provide APCM services. Here is who can provide APCM services to patients.

1. Physicians (MD, DO)- Licensed medical doctors and doctors of osteopathy are authorized to provide care using APCM. They serve as the primary decision-makers and offer personalized care plans, especially for patients with multiple chronic conditions.
2. Nurse Practitioners- NPs with proper license and authority can management patient care and use the Advance Primary Care model. They can also prescribe medications and deliver chronic care services independently.
3. Physician Assistants- PAs working using the supervision of a physician can use APC models to deliver routine follow-ups, care coordination, and preventive care.
4. Certified Clinical Nurse Specialists- CNSs who specialize in chronic disease management or geriatrics can support APCM by checking high-risk patients and ensuring evidence-based interventions.
5. Federally Qualified Health Centres (FQHCs)- FQHCs are community-based clinics that offer primary care to residents of underserved areas. They offer coordinated care to vulnerable populations, and thus, they are also qualified to participate in APCM.
6. Rural Health Clinics- Like FQHCs, RHCs offer services in undeserved rural communities. They can incorporate the APC model to reduce hospitalization rates, improve chronic disease management, and get additional Medicare reimbursements in rural areas.

Compliance with CMS Standards 

Providers who deliver APCM services and receive reimbursement must comply with the Centers for Medicare and Medicaid Services guidelines. These include-

• Maintaining documentation of care plans, time, and patient consent.
• Using a certified Electronic Health Record (EHR) for tracking and reporting data.
• Adhering to billing rules associated with CCM, RPM, and TCM, etc.
• Meeting benchmarks for patient engagement, team collaboration, and quality.

Note: Providers who fail to comply with the guidelines may be subject to denied claims or audits. 

Billing and Reimbursement for Advanced Primary Care 

The Advanced Primary Care model integrated diverse CMS-recognized billing codes. This allows providers to get reimbursement for the delivery of diverse care models virtually and in person. This strength of the APC model makes clinics financially sustainable and capable of offering value-based services.

Instead of relying on the fee-for-service (FFS) model, APC combines monthly reimbursements with performance-based incentives. Here is a breakdown of the billing components used in APCM.

1. Chronic Care Management 

Applicable CPT Codes- 99490 (for 20 minutes of interaction in cases of non-complex chronic care management) and 99439 (for each additional 20 minutes of care).

These codes are used to bill for care coordination and management offered to Medicare patients with two or more chronic conditions. Reimbursement insights-

• • CPT 99490 reimburses around $42 per patient monthly.
  • The reimbursement can scale to $130 monthly with CPT 99439 add-ons.
  • CCM offers recurring revenue.

2. Remote Patient Monitoring (RPM) 

Applicable CPT Codes- 99457 (for 20 minutes of interactive care) and 99458 (for each additional 20 minutes of RPM service).

These codes are applicable when care providers analyze patients’ vitals and data using FDA-approved devices. It is ideal for patients with chronic diseases who require ongoing oversight. Reimbursement insights-

• • CPT 99457 reimburses around $50-$55 monthly.
  • CPT 99458 adds $40-$45 to the reimbursement.
  • RPM enables providers to enhance reimbursements and provide chronic care without increasing traffic and in-person visits to the clinic.

3. Transitional Care Management (TCM)  

Applicable CPT Codes- 99495 (to provide care to discharged patients with moderate complexity within 14 days of discharge) and 99496 (for high complexity discharge management for 7 days post-discharge).

Transitional Care Management (TCM) codes facilitate reimbursement for services delivered to patients during the critical period following hospital discharge. It aims to reduce the risk of readmission and includes medication reconciliation, follow-up appointments, and more. Reimbursement insights-

• • CPT 99495 reimburses up to $200 per patiently monthly.
  • CPT 99496 can help providers go up to $250 per patient in reimbursements.
  • TCM is billable in addition to CCM, making a significant addition to ongoing care plans.

The APCM framework incorporates value-based mechanisms that incentivize providers to improve care quality, operational efficiency, and patient experience. The reimbursements include Care Management Fees (CMFs), Pay-for-Performance Bonuses, and income generated from the Shared Savings Program. This structure ensures providers are compensated for both the volume and the value of care delivered to patients.

Learn More About CPT Codes 

What are the Benefits of APCM for Patients? 

APCM is designed to offer a patient-centric healthcare experience, particularly for patients with chronic illnesses. Patients are active participants in this ongoing care journey, which leads to better results with continuous engagement. Here’s how APC delivers value and better care to patients-

1. Improved Health Outcomes- Patients are actively involved in monitoring their vitals. They interact with their care team via phone and video calls or remote monitoring. This enables providers to make timely interventions and more effective disease management, leading to lower complication rates and better patient health outcomes.
2. Personalized Care Plans- APC promotes individualized care, offering patients treatment plans that align with their medical history, lifestyle, and risk factors. For example, a patient struggling with diabetes can receive dietary counselling, medication reminders, and RPM device support to monitor their blood sugar levels.
3. Round-the-clock Access to Care Teams- Without having to visit the clinic regularly, patients can access their care coordination teams 24/7. They can ask questions, report concerns, and receive guidance from their nurses, care managers, and other health providers, reducing delays.
4. Reduced Hospital Utilization- Integrating Advanced Primary Care allows for closer patient monitoring, which helps prevent emergencies and reduces financial strain for both providers and patients.
5. Preventive Focus for Enhanced Quality of Life- APC emphasises prevention, lifestyle modification, and early detection. Thus, it ensures that patients maintain mobility and mental well-being. Through education and self-management tools, patients are more invested in their health compared to old times.

How to Implement the Advanced Primary Care Model?

While implementation of the Advanced Primary Care model is not rocket science, it demands a strategic and systematic approach. Let us break down the details about APCM implementation.

Resources Required 

Establishing an Advanced Primary Care framework, providers must invest in

• Care management platform- for documentation, analytics, and care tracking (such as CCM, RPM, TCM, etc.)
• Clinical staff- including care coordinators, nurses, pharmacists, health specialists, and social workers, if required.
• Telehealth and RPM technology- tools that help remote patient monitoring and virtual consultations for patients.
• Training- programs to train providers and their staff to use technology and understand workflows, billing protocols, and compliance standards.

Steps Involved 

Here are the steps you need to follow for the successful implementation of APC.

1. Evaluate your practice readiness- Check the clinical infrastructure, staffing capacity, documentation tools, and intake of population, and look out for gaps. Ensure you are ready to inculcate APM into your practice.
2. Choose technology partners- Search for CMS-compliant vendors who are ready to assist you in setting up the devices (like RPM and RTM) and guide you about their usage. Choose scalable and CMS-compliant vendors with a strong background in the industry and several testimonials.
3. Train your staff- Offer comprehensive training to your staff and help them understand the APC model. Designate responsibilities and teach them billing codes and documentation requirements. Promote collaboration and teamwork for the best results.
4. Create SOPs- Formulate standard operating procedures for enrolment, documentation, follow-ups, and escalation protocols to ensure standardization, quality, and compliance.
5. Educate your patients- Inform your patients about the benefits of APCM and motivate them to engage with the new model and its tools. Use consent forms to onboard them and formalize participation.
6. Monitor and refine performance- Use KPIs such as hospital readmissions, patient satisfaction, and reimbursements to track performance of the APC model. Using these insights, bring necessary changes, conduct training, and optimise workflow.

Challenges 

Implementing APCM is not free of obstacles. Here are some key challenges you should be prepared to address:

• Initial capital investment – APC offers long-term financial gains to providers, but the initial investment in technology and training may be substantial.
• Complex billing- Understanding the CCM, RPM, and TCM codes requires extensive knowledge and training and may seem like a challenge initially.
• Patient adherence- Motivating patients, especially older adults, to trust technology and engage with it may be a strenuous task.
• Data integration- Synchronizing patient data across care management tools and EHRs, RPM platforms can be complex and may require expert support.

Get Support in Implementing APCM

Key Government Initiatives Promoting APCM 

The U.S. government aims to promote APCM integrate to enhance the level of care offered to patients by providers. Federal agencies such as CMS have launched numerous initiatives to encourage APC adoption. This includes technical support and financial incentives for the stakeholders. Below are key government initiatives driving the adoption of APCM:

1. Comprehensive Primary Care Plus (CPC+): CPC+ is a multiplayer initiative led by CMS. It aids the delivery of advanced and coordinated primary care via healthcare setups. Providers participating in this initiative get access to real-time data along with care management fees and performance-based incentives.
2. Primary Care First (PCF) : This government program aims to incentivise practices that highlight improved patient results and reduced care costs. PCF offers risk-adjusted, population-based payments and is extremely beneficial for small and mid-sized practices.
3. Realizing Equity, Access, and Community Health (REACH): ACO has brought out the REACH program, benefiting providers who promote equity-driven, value-based care. By participating in this program, providers can share in savings generated by reducing avoidable expenses and improving care quality.

Apart from this, government support to promote APCM includes infrastructure grants, care management payments, technical assistance, training resources, data sharing, shared savings arrangements, and population health tools.

The Future of Advanced Primary Care Management 

Advanced Primary Care Management focuses on providing quality care with better patient outcomes at lower costs. While it is destined to transform care delivery across the U.S., here are the key future trends that providers may witness in the realm of APC.

• Hybrid Care Models- Practices with blend virtual care with in-person care, improving efficiency and reducing the burden on the staff.
• AI-Driven Risk Analysis- To avoid emergencies and promote precise interventions, AI tools will be used to identify at-risk patients.
• Growth of Direct Primary Care- Subscription-based models can be implemented alongside APCM to provide patients with a wider range of payment options.
• Mobile Health Engagement- Apps and digital tools will be used to drive patient engagement with reminders and health tracking.
• Expansion of Value-Based Care- The value-based care industry will experience a boom with more providers entering shared savings and risk-sharing programs.

APCM continues to be a cornerstone of patient-focused healthcare that enables providers to achieve better outcomes at lower costs. It bridges the gap between cost, quality, and accessibility, transforming healthcare in the future.

Final Words 

Advanced Primary Care Management has come a long way from traditional care models, empowering care providers to achieve better results and reimbursements. The role of APCM does not limit itself to better care services but also supports small clinics and their staff. A combination of APCM with AI, Remote Patient Monitoring, and other vital technologies can help you scale your health practice exponentially.

Advanced Primary Care Management ( APCM) is a strategic transformation that enables practices to thrive in an evolving, outcomes-driven healthcare ecosystem.

However, successful implementation requires the right tools and a dependable technology partner, supported by a scalable yet straightforward framework.

Why Choose HealthArc for APCM Implementation? 

HealthArc’s pioneering AI-driven APCM platform assists providers throughout the entire process—from launching new care programs to maximizing reimbursement. Our services deliver a unified, compliant, and personalized care experience.

HealthArc integrates Chronic Care Management (CCM), Principal Care Management (PCM), and Transitional Care Management (TCM) into a seamless workflow. It ensures CMS compliance while automating billing processes. With 24/7 access and multi-channel communication, we help you create an accessible environment for patients requiring round-the-clock support.HealthArc ensures seamless system integration and a swift launch, making the transition to APC stress-free for practices. As a trusted partner, HealthArc provides the confidence and expertise needed to help your small practice scale effectively.Schedule a consultation with HealthArc to discover how our platform can help you confidently launch an APCM program. Book a free demo

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