Chronic Care Management Services

Medi Remote provides chronic care management (CCM) support services that help medical practices manage eligible patients under structured workflows and care coordination assistance.
Our model supports CCM program execution by combining workflow tools with trained care coordinators who assist your practice with patient engagement and documentation tasks under clinical direction.

Patient eligibility support and enrollment coordination
Monthly patient outreach and follow-up support
Documentation and care coordination assistance
CCM time tracking and reporting support

A Fully Managed CCM Solution for Busy Practices

Many medical practices use CCM tools to manage patients with chronic conditions. However, day-to-day execution of outreach, documentation, and care coordination still requires consistent operational effort.

Medi Remote supports these workflows by providing care coordinators who assist with patient engagement and documentation tasks under the direction of your clinical team. This includes structured monthly follow-ups and updates to care records as part of ongoing CCM program activities.

Clinical decisions and care plans remain fully under the responsibility of the medical practice, while Medi Remote focuses on supporting the operational workflow of the CCM program.

Step-by-Step Patient Coordination Workflow

A PCM program allows specialty practices to bill for the non-face-to-face care coordination they already provide for patients with a single, complex chronic condition.

Medi Remote helps reduce the operational workload required to run these programs by supporting patient onboarding, monthly care coordination activities, and billing documentation so your clinical team can stay focused on in-office care.

Finding Eligible Patients

We help review patient lists to identify individuals who may qualify for CCM enrollment.

Enrollment and Consent

Our team supports outreach and helps communicate program details to patients.

Monthly Patient Follow-Up

Scheduled check-ins are carried out and patient updates are recorded for review.

Care Documentation

Notes from each interaction are organized and shared with the clinical team.

Program Administration

Coordination activity is tracked to support reporting and billing workflows.

Complete Chronic Care Support Across All Major Specialties

Older patients often face confusing communication between different doctors, labs, and pharmacies. To fix this, our chronic care management services build simple, personalized care plans that keep all health updates in one easy-to-use dashboard.

Our remote clinical staff works closely with your practice to handle all the daily tracking and paperwork across these key specialties:

Cardiology

Checking blood pressure trends between office visits and tracking lifestyle changes.

Nephrology

Helping patients manage fluid limits, diet changes, and required kidney lab tests.

Endocrinology

Tracking Type 2 diabetes plans, watching insulin schedules, and checking lab timelines.

Pulmonology

Checking daily oxygen levels and inhaler use to catch breathing issues early.

Internal Medicine

Coordinating care for complex, long-term conditions to keep patients stable at home.

Family Medicine

Supporting routine health goals and managing everyday care plans for your entire patient panel.

Medical Devices Your Patients Can Use at Home

We provide simple, connected home devices that automatically send health readings straight to our care managers. This keeps your patients safe and removes the need for manual data logging.

Blood Pressure Monitor

Glucometer

Pulse Oximeter

Weight Scale

Care Coordination Tools for Chronic Care Management

Keeping up with a Chronic Care Management program takes time. Between monthly patient calls, documentation requirements, and ongoing follow-up, many practices struggle to fit CCM responsibilities into an already busy schedule.

Medi Remote helps by providing care coordinators who support these day-to-day activities under your practice’s direction. While your providers remain responsible for clinical decisions, our team helps keep patient communication and documentation on track.

Core Care Management Workflows

Personalized Care Plans

We maintain care plan records and document patient goals based on the guidance provided by your clinical team.

Monthly Patient Outreach

Our coordinators contact enrolled patients each month, discuss ongoing health concerns, and document the interaction.

Care Coordination Support

We help organize patient updates, medication discussions, and follow-up information so providers have access to current records when needed.

Documentation Tracking

Care management activities and monthly interaction time are recorded throughout the program to support CCM reporting requirements.

Compliance Support

Our team maintains organized records and documentation to help practices meet CCM program requirements.

Real Clinical Benefits for Your Most Vulnerable Patients

Implementing structured chronic care workflows helps practices better organize patient monitoring, improve care coordination, and maintain more consistent follow-up for high-risk populations.

This allows providers to shift more focus toward proactive care planning supported by regular data and communication from enrolled patients.

Primary Care Support

Helps clinics monitor long-term trends and support earlier identification of changes in patient health.

Specialty Care Coordination

Organizes ongoing patient data to support continuity of care across different specialists.

Care Gap Management

Supports tracking of required follow-ups and documentation needed for value-based care programs.

Transition Support

Assists with continuity of information when patients move between hospital and home care settings.

Increase Revenue While Improving Patient Care

Launch our full-service clinical framework today to maximize your monthly revenues and improve chronic patient outcomes across your entire medical group without adding any operational workload to your clinic.

Stay Compliant With Precision CCM Reimbursement Tracking

Our system logs every device setup, data transmission, and care interaction so your office has the exact records needed for smooth billing.

Service Type

Non-Complex CCM

CCM Extension

Complex CCM

Complex Extension

CPT Code

99490

99439

99487

99489

Service Description

Initial 20 minutes of monthly care management services provided by clinical staff.
Each additional 20-minute block of clinical staff time within the same calendar month.
60 minutes of complex care coordination requiring higher medical decision complexity.
Each additional 30-minute block of complex care coordination time.

Average Reimbursement

$66.13

$50.44

$144.29
$78.16

Comparing Isolated Software Against Managed Partnerships

Standard software vendors provide tools and leave daily execution to your internal staff. Medi Remote provides an operational support layer that helps your team manage remote care workflows more efficiently.

The Daily Work

Patient Engagement
Monthly Care Minutes
After-Hours Coverage
Medication Tracking
Billing Records

Standard Software

Your staff must call and sign up eligible seniors.

Your nurses must log 20+ minutes per patient.

Your on-call doctors handle urgent patient calls.

You manually cross-reference pharmacy refills.

You manually trace and count care minutes.

The MediRemote Model

We support onboarding workflows. Our team assists with consent and setup coordination.
We support outreach workflows. Our coordinators help facilitate monthly engagement tracking.
We support after-hours communication. Patient concerns are routed appropriately for provider review.
We collect medication updates. Information is shared for provider review and documentation.
We log activity. Structured records are prepared to support billing workflows.

Why Practices Choose Medi Remote

Standard software tools typically require internal staff to manage patient outreach, documentation, and care coordination tasks. Medi Remote combines HIPAA-compliant software with trained care coordinators who support these workflows as part of your CCM program.

This structure helps practices maintain consistent program execution while working alongside their existing clinical team. All activities are performed under the direction of the medical practice.

Support for Care Workflows

Our team assists with patient outreach and coordination tasks so internal staff can focus on clinical care.

Structured Documentation Support

Patient interactions and care activities are recorded within the Medi Remote platform for review and reporting purposes.

Platform-Based Records

Care coordination notes, updates, and patient activity logs are securely maintained in the Medi Remote system for ongoing RPM management.

Enrollment Assistance

Our onboarding team helps communicate program details to patients and supports the consent process.

Give Your Team More Time for Patient Care

Free your clinical team from chasing patient data and compliance paperwork. Our full-service framework provides the staff and technology your practice needs to save time, protect your schedule, and secure predictable revenue.

Frequently Asked Questions

What is remote patient monitoring?

It is a way for doctors to track patient vitals like blood pressure or weight from home using cellular medical devices that automatically send data straight to the clinic.

Patients use our cellular devices at home. The readings automatically sync to our system, where we review the data and flag issues for your staff.

We handle all background work like shipping home devices, calling missing patients, tracking care minutes, and sorting incoming daily data logs.

No, your practice does not need to hire anyone. Our dedicated clinical team manages the daily operations for you.

We provide full operational management for Remote Patient Monitoring, Chronic Care Management, and Principal Care Management structures.

Our monitoring devices use built-in cellular networks. Patients just turn them on without needing Wi-Fi, smartphone apps, or Bluetooth.

We procure and deliver devices to your practice or facility, where they are distributed to patients. Our support line handles all technical troubleshooting directly.

We deliver complete, structured time-tracking logs and clinical summaries at the end of every month for clean claim submissions.