Supporting Your Care

Lacuna Health’s clinical teams engage patients on behalf of your practice, enabling more coordinated healthcare for the patients you serve.

Effectively Manage Your Resources with Chronic Care Management (CCM)

Helping You Close Gaps With Annual Wellness Visits

Improve Outcomes and Cost for Your Chronic Illness Patients

Generate Revenue While Improving Care

Effectively Manage Your Resources with Chronic Care Management (CCM)
Make the Most of Your Time with Some of Ours

If you’re a primary care physician, you already know that patients with chronic illnesses require more intensive care management, especially in-between visits to the practice. Adding home and community care management programs can be burdensome to operationalize, since they are centered outside the office setting and typically involve hiring additional clinical staff. ​

Lacuna Health eliminates many of these barriers to entry. Our RN-led care teams can partner with you to remotely manage your chronically ill patients outside of the office setting while also helping your bottom line. ​ ​

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions. ​

At Lacuna Health, our CCM services benefit our practice partners in a number of ways:​ ​ ​

  • Conducting monthly, non-face-to-face conferences of at least 20 minutes with these patients, helping your office meet the CMS requirements of CPT 99490
  • Developing comprehensive care plans reviewed and approved by the practice
  • Effecting medication reconciliation to avoid errors and support patient compliance
  • Keeping physicians notified about a patient visit to an ER, hospital or SNF
  • Coordinating with specialists as well as home and community-based service providers ​

These services provide continuity of care between office visits and help aggregate clinical and patient information to create a holistic view of the patient’s care. We can even connect to your EHR, allowing our CCM care team to review necessary patient care information. ​

Helping You Close Gaps With Annual Wellness Visits
Helping You Close Gaps With Annual Wellness Visits (AWVs)

The Annual Wellness Visit (AWV) is a yearly appointment with a primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on patient health and risk factors. Medicare Part B pays for the AWV under CPT 99213 if the patient: ​

  • Has had Part B for over 12 months
  • Has not received an AWV in the past 12 months ​

Lacuna Health helps your practice efficiently manage AWV scheduling to generate additional revenue while capturing patient information, updating patient medical histories and screening for other conditions such as dementia or Alzheimer’s. Our scope of services includes:

  • Patient outreach and scheduling of AWV appointments; capturing data via HRA to streamline the process for physicians
  • Capturing and documenting HEDIS measures and star ratings
  • Delivering a personalized preventative care plan to the provider and patient
  • Identifying downstream opportunities to improve and maintain health (e.g. depression screenings, advanced care directives, alcohol screening)
  • Enrolling patients into a CCM program ​ ​ ​ ​ ​
Improve Outcomes and Cost for Your Chronic Illness Patients
Putting Patients at the Center of Care

​ Research has shown that regular interactions with a dedicated care team improves overall health and wellness, while helping patients avoid hospital stays and high out-of-pocket expenses. Telephone checkups are an effective way to monitor care plans, medications and any new symptoms or health concerns patients may have.

Our RN-led care teams communicate with you and your patients to help them manage their conditions. We help monitor symptoms, reduce the barriers to treatment between physician visits and personalize care management services to each individual patient.

We manage a patient’s condition
so that they aren’t managed by their condition.

Generate Revenue While Improving Care
AWVs and CCM Makes Sense for Your Patients and Cents for Your Practice

Healthcare is always changing. Lacuna Health can help your practice most effectively execute on CMS-sponsored care management programs. Lacuna Health removes barriers to implementing and efficiently managing AWVs (CPT G0438) and/or CCM (CPT 99490) programs, which not only helps improve patient outcomes, but also increases your practice revenues.

Reach out to us to reach your patients.

© 2022 Lacuna Health

© 2021 Lacuna Health