Chronic Care Management

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The Impact of CHronic Conditions

Chronic diseases are the number one cause of death and disability in the United States.

Of Adults
Affected Population

Sixty percent (60%) of adults have at least one chronic illness.

Of Spending
Economic Impact

Treating patients with chronic diseases accounts for 75% of the nation's healthcare spending.

Of Medicare Beneficiaries
Multiple Chronic Conditions

Two-thirds of Medicare beneficiaries have multiple chronic conditions.

Understanding Chronic Care Management

This animated video provides chronic care management (CCM) services information for Medicare beneficiaries living with multiple chronic conditions. Watch this video to learn more about the benefits of participating in CCM services.

who Is Eligible to participate in Chronic Care Management?


Any Medicare patient with two or more chronic conditions expected to last at least 12 months or until the patient’s death and/or that place them at significant risk of death, acute exacerbation and/or decompensation, or functional decline is eligible to participate in a CCM plan.

There are many chronic conditions including:

  • High blood pressure
  • High cholesterol
  • Diabetes
  • Heart disease
  • Depression
  • Eye diseases & those risks related to diabetes, high blood pressure and other chronic conditions


These physicians and Non-Physician Practitioners (NPPs) may bill CCM services: 

  • Certified Nurse Midwives (CNMs)
  • Clinical Nurse Specialists (CNSs)
  • Nurse Practitioners (NPs)
  • Physician Assistants (PAs)

Note:  Primary care practitioners most often bill CCM services, but some specialty practitioners may furnish and bill them as well.

How Chronic Care Management Works


Need Recognition

Chronic Care Management (CCM) is a critical component of care that contributes to better outcomes and higher satisfaction for patients. The Centers for Medicare & Medicaid Services (CMS) recognizes CCM takes time and effort.


WIN-WIN Opportunity

CMS established separate payments under billing codes for the additional time and resources you spend to provide the between-appointment help many of your Medicare and dual eligible (Medicare and Medicaid) patients need to stay on track with their treatment plans for better health. 



The Well Living Initiative team reaches out to patients monthly to make sure that they are staying on track with their care plan and assisting with care coordination, and their social and economic needs.

Chronic Care Management Benefits

Besides improving patient health and connection, utilizing the WLI team, the estimated net annual revenue for each 1,000 patients enrolled in the chronic care management program is $2 million.

Care Plan Adherence Increases, Reducing Care costs per beneficiary

Patient health issues are addressed between appointments. CMS documented how CCM saved on average $74/month per beneficiary in a 2017 study. 

Reduce Disparities & Treat More Patients

CCM services help reduce geographical, racial, or ethnic health care disparities.  These services aren’t typically face-to-face and allow eligible practitioners to bill at least 20 minutes or more of care coordination services per month.

Better Patient Care, Increased Practice Revenue

Adding CCM improves patient health outcomes and accesses an untapped source of revenue for medical practices. 

Estimated PBPM impact of CCM

Our Services


Here's what your patients can expect with Well Living Initiative Chronic Care Management. 

  • Your advocate will assist with care coordination, referrals, and the complexities of healthcare.
  • Monthly check-ins and ready access to your care team to improve care coordination.
  • Assistance with local resources, community support.
  • Being there to hear their concerns, assist with social and economic fears.
  • A team of dedicated health care professionals who can help you plan for better health and stay on track.


Here's what your practice can expect with Well Living Initiative Chronic Care Management. 

  • Improve Care Coordination with other providers.
  • Support patient compliance and help patients feel more connected.
  • Financial Navigation Programs that decreases financial distress for the patient and increases financial stability for the provider – reduce financial toxicity.
  • Sustain and improve profitability for your practice.  Offering WLI may provide you with increased profitability, improved patient care resulting in higher MIPS scores.
  • The medical office would NOT need to hire additional staff.
  • Fi-Med handles all of the administration work and conversations with the patients.
  • Appointments with WLI patients will run more efficiently and effectively as the physician will know of any patient concerns or issues prior to the start of the appointment.

What Are You Waiting For? Make a real change Now!