Chapter 5

PATIENT CENTRIC SERVICES

 Hospital HHAH

Diagnosis (ICD)

DME

Patient and Family PG

Pre-Auth
Lab

Pre-Auth

Pre-Auth

Pharmacy

Claims (CPT, G0179,G0180,G0181) Insurance

Medicare Medicare advantage Medicaid Private

Mediated Communicators of Healthcare

After exploring how Home Health Agencies contribute to patient-focused care, let’s
shift our focus to another aspect of the healthcare journey: pharmacies and
laboratories. These entities play a role in helping patients access medications,
durable medical equipment (DME), and essential diagnostic services.
 Hospital HHAH

Diagnosis (ICD)

DME

Patient and Family PG

Pre-Auth
Lab

Pre-Auth

Pre-Auth

Pharmacy

Claims (CPT, G0179,G0180,G0181) Insurance

Medicare Medicare advantage Medicaid Private

Pharmacies
Pharmacies dispense medications to patients based on prescriptions from physicians.

After a diagnosis, the physician may prescribe medication, which is usually sent
electronically to the patient’s preferred pharmacy. There, the pharmacist steps in to
ensure the medication is safely dispensed, checking for insurance coverage and
potential drug interactions. If any issues arise, the pharmacist collaborates with the
physician to clarify or adjust the prescription, ensuring seamless and safe care for the
patient.

Sometimes, the prescribed medication needs approval from the insurance company
before it can be covered. This is called prior authorization (pre-auth). It’s a process
where the insurance checks if the medication meets their coverage guidelines.
 Hospital HHAH

Diagnosis (ICD)

DME

Patient and Family PG

Pre-Auth
Lab

Pre-Auth

Pre-Auth

Pharmacy

Claims (CPT, G0179,G0180,G0181) Insurance

Medicare Medicare advantage Medicaid Private

Laboratories
Laboratory services are a vital part of the diagnostic journey, offering important tests
like blood work, imaging studies, and biopsies that help doctors confirm diagnoses.

When a physician orders these tests, patients are referred to laboratories, where the
samples are processed and analyzed. The results are then electronically integrated
into the patient’s electronic health record (EHR) for review by the healthcare
provider.

In some cases, certain lab tests may require prior authorization (pre-auth) from the
insurance company to ensure they meet the coverage criteria. This process helps
avoid unexpected costs and ensures that the patient receives the necessary tests in a
timely manner, allowing the physician to proceed with an informed treatment plan.
 Hospital HHAH

Diagnosis (ICD)

DME

Patient and Family PG

Pre-Auth
Lab

Pre-Auth

Pre-Auth

Pharmacy

Claims (CPT, G0179,G0180,G0181) Insurance

Medicare Medicare advantage Medicaid Private

DME
Many patients need medical equipment to support their recovery or manage chronic
conditions. Items like wheelchairs, oxygen tanks, and prosthetics are commonly
prescribed, and the process of referring patients for durable medical equipment
(DME) ensures they receive the right tools for their care.

The referral helps confirm that the equipment is suitable for the patient’s needs and
that insurance coverage is handled appropriately.

DME suppliers often collaborate directly with physicians to make sure the prescribed
equipment meets both the patient's requirements and the insurance provider's
criteria.
 Hospital HHAH

Diagnosis (ICD)

DME

Patient and Family PG

Pre-Auth
Lab

Pre-Auth

Pre-Auth

Pharmacy

Claims (CPT, G0179,G0180,G0181) Insurance

Medicare Medicare advantage Medicaid Private

The Role of DA in all the processes

Doctor Alliance (DA) is the behind-the-scenes superhero, connecting the dots
between physicians, pharmacies, laboratories, and DME suppliers to keep everything
running smoothly. Think of DA as the ultimate team player, making sure information
flows seamlessly and services are delivered without a hitch. From ensuring quick
medication approvals to helping labs and DME suppliers meet patient needs, DA
makes the process faster, easier, and more efficient—so everyone can focus on what
really matters: patient care.
 Increased Episode BIllability

Patient Physician Ancillary Services

Increasing cash flow
Group

Abstracting communication with Physician Groups

Home Health Pharmacies Laboratories DME

Documents to be signed

Start of Care End of calendar month End of Episode Recertification Recert

60 days

485 cert signed Care minutes are alloted 485 cert signed
Claim Submission

Additional Care
coordination is performed
G0179 are filed
G0180 is filed Achieving 30 minutes of care

G0181 is filed

Let’s take a closer look at patient-centric services

Now that we have understood the ancillaries, lets take a closer look at the patient
centric services and how they are done!
Envision the patient at the center of focus, with each service seamlessly interwoven
to deliver a comprehensive care.
 Patient Centric Services

RPM CCM Laboratories

Life Cycle
Pre - Auth

n1

n2....nn

2 1 1 2
Physician
Group Hospital

Patient Centric Services

TCM

Home Health

Care Plan Oversight

Pharmacies
DME

Pre-Auth
Life Cycle
Life Cycle Pre - Auth

n1
Pre - Auth

n1 n2....nn

n2....nn
 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Care Plan Oversight

Care plan oversight involves the
Lets recall ! What is it? physician’s responsibility to monitor
and coordinate the care being
provided by a Home Health Agency
to ensure it aligns with the patient’s
health needs and goals.

What does the Patient get ?

Coordinated Care

Personalized Supervision

Increased Trust and Assurance

 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Care Plan Oversight

Understanding the importance of Care Plan Oversight really hits home when we
think about what would happen without it. Without proper oversight, doctors
would still have to go through endless paperwork and manage patient care without
getting the reimbursement they need. This would not only add to their
administrative burden but also increase the chances of mistakes and inconsistencies
in treatment.

While Care Plan Oversight (CPO) is essential for delivering comprehensive and high-
quality patient care, effectively implementing it demands time and resources that
busy physicians often lack.

That’s where Doctor Alliance steps in. We handle all your administrative tasks, the
whole lifecycle in its essence and boost your revenue with a group of intellectuals
working behind the scenes.

"Understanding the why behind CPO sets the stage—now let’s uncover how the
CPOs are done!”
 Caution ! - Steps ahead

As we dive into the steps of Patient-Centric Services, let’s

remember: we’re not just going through the motions like
Mechanical Monkeys!

In the world of healthcare, things can change in an instant. So,

let’s be flexible! If a particular approach isn’t working, don’t
hesitate to pivot.

Curiosity is our best friend! Approach each step with an open

mind and a willingness to learn.
 Home Health

Documents to be
signed
Start of Care End of calendar month End of Episode Recertification Recert
60 days

485 cert signed 485 cert signed

Care minutes are alloted
Claim Submission

G0181 are filed G0179 are filed

G0180 are filed

Care Plan Oversight - Claim Submission for HouseCall MD

The first step in submitting a claim is to check whether the claim for the
code has been submitted or not.

If the claim is not submitted, then proceed with the billing.

Click on the Quick charge entry logo in AdvancedPM

Search for the last name of the patient in the Quick charge entry section
and open the popup

Enter the code of respective provider.

Change the DOS or Date of Service by referring to the Master billing

sheet.

Enter the billing code and 6 ICD-10 codes, Recheck everything and click
on process.
 Patient Centric Services - TCM

RPM CCM Laboratories

Pre-Auth

More Steps incoming

2 1 1 3
Physician
Group Hospital

Patient Centric Services

TCM

Home Health

Care Plan Oversight

Pharmacies
DME

Pre-Auth

More Steps incoming

More Steps incoming

 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Transitional Care Management

Transitional Care Management (TCM) is all about ensuring that patients smoothly
transition from the hospital back to their everyday lives.

When someone is discharged, TCM steps in to oversee their care and help prevent
them from needing to be readmitted within thirty days. To make this happen, a
face-to-face visit with the patient must take place within the first month after they
leave the hospital. By managing this crucial period, TCM provides the support and
follow-up care needed to keep patients on track with their recovery, ensuring they
receive the attention they need right when they need it most.

CPO TCM

We will confer to the whole process of TCM in the later editions, for now lets move
on to Pre-Authorization.
 Patient Centric Services - PA

RPM CCM Laboratories

Pre-Auth

More Steps incoming

2 1 1 3
Physician
Group Hospital

Patient Centric Services

TCM

Home Health

Care Plan Oversight

Pharmacies
DME

Pre-Auth

More Steps incoming

More Steps incoming

 Patient Centric Services - PA

Patient visits the

practitioner

Updating Stakeholders

Physician issues a prescription for

medicines and/or diagnostic procedures

Appeal Process

Do these medications/lab tests

No require pre-authorization ? Review reasons for
Yes denial

No action needed
Follow Pre-Authorization
process & submit data to
insurance companies

Insurance
Approved Denied
Approval

Patient goes to
Patient proceeds pharmacy for
to lab for tests medication
 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Pre - Authorization
Imagine you’re planning a big trip and need to get all your documents in order
before you can set off. In healthcare, pre-authorization works much like securing
those essential travel permits. It’s a step that ensures everything is approved and
ready before you receive certain medical services, procedures, or medications.

When your doctor recommends a specific treatment or medication, your insurance

company steps in to review the request. Think of them as the gatekeepers making
sure that the proposed care is necessary and covered under your plan. This process
helps prevent unexpected costs and ensures that you get the right care at the right
time.

We will confer to the whole lifecycle of PA in the later editions, for now lets move
on to Chronic care management.
 Patient Centric Services - CCM

RPM CCM Laboratories

Pre-Auth

More Steps incoming

2 1 1 3
Physician
Group Hospital

Patient Centric Services

TCM

Home Health

Care Plan Oversight

Pharmacies
DME

Pre-Auth

More Steps incoming

More Steps incoming

 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Chronic Care Management

When it comes to patients with chronic conditions, their claims can be filed under
Chronic Care Management (CCM). To qualify for CCM, there needs to be a face-to-
face visit within the past year.

It’s also important to know that CCM and Care Plan Oversight (CPO) can’t be billed
at the same time. So, if someone is managing a patient with two chronic conditions,
they’ll need to choose between CCM and CPO for their care and billing. This ensures
that each service is used effectively without any overlap, helping both patients and
providers stay organized and efficient.

We will confer to the whole process of CCM in the later editions, for now lets move
on to Remote Patient Monitoring.
 Patient Centric Services - RPM

RPM CCM Laboratories

Pre-Auth

More Steps incoming

2 1 1 3
Physician
Group Hospital

Patient Centric Services

TCM

Home Health

Care Plan Oversight

Pharmacies
DME

Pre-Auth

More Steps incoming

More Steps incoming

 Care Coordination

Consent Calling

CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Remote Patient Monitoring

Imagine doctors being able to keep a close eye on your health without you ever
leaving your home. That’s the power of Remote Patient Monitoring!

Remote patient monitoring also helps you save on travel costs and reduces the risk
of infections by minimizing the need for in-person visits. It’s a win-win for both
patients and providers, ensuring that quality healthcare is accessible, efficient, and
safe
 Caution ! - Steps ahead

As we dive into the steps of Patient-Centric Services, let’s

remember: we’re not just going through the motions like
Mechanical Monkeys!

In the world of healthcare, things can change in an instant. So,

let’s be flexible! If a particular approach isn’t working, don’t
hesitate to pivot.

Curiosity is our best friend! Approach each step with an open

mind and a willingness to learn.
 Care Coordination

Consent Calling

CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Remote Patient Monitoring - Consent Calling

Call the patient/caregiver using the GoTo app.

Introduce yourself.

Purpose of your call.

Get the consent.

Verify and note down the name of the person giving consent.

Verify the address at which the Machine will be deployed to.

 Care Coordination

Consent Calling

CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Remote Patient Monitoring - Consent Calling

Sample Script
Hi,

This is Sierra,

I am calling on the behalf of XYZ Medicines, This is regarding your last visit with
provider (XYZ).

Your provider would like to measure your X readings. So we would like to bring out
Y machine and show you how it works.

Are you ok with it ?

 Care Coordination

Consent Calling

CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Most Common Questions by patients/caregivers

Sample Script
Why should I get this Machine if I already have one ?

This is on your providers request, the reading will be electronically transmitted to

your provider in real time, making the monitoring of your health in a better
manner.

Do I have to pay for this ?

No, This will be billed against your insurance.
 Care Coordination

Consent Calling

CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Remote Patient Monitoring - Care Calling

Care coordination in Remote patient monitoring is done through care calls

To perform care calls, “Bridge” is used to maintain the records and thereby create
appointments for the patients at the same time.

It creates a bridge between the healthcare providers and the patients, monitoring
their health outcomes remotely.

In our earlier chapters, we explored the crucial roles of CPT codes, billing codes, and
ICD codes in the healthcare system. Now, it’s important to highlight that CPT codes
are also integral to securing reimbursement for Remote Patient Monitoring (RPM)
services.
 CPT Codes

99453
Care Coordination
99454

Consent Calling
99457

99458

CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

 CPT Codes 99453
Care Coordination
99454
Consent Calling
99457

99458

CCM RPM

Patient Centric Services Physician

Group

Remote Patient Monitoring - Care Calling

Login into the Bridge Portal Home

Patient listing Alert

Select patient with incomplete care coordination minutes i.e patients with less than
20/40 CC minutes

Select patient with incomplete care coordination minutes i.e patients with less than
20/40 CC minutes

Start the timer in the portal

Cross - Verify Patient Details in the EHR, Check the readings.

Call the patient using your GoTo credentials and try to complete the care
coordination minutes

Take a note of the conversation in the notes section

Stop the timer when you end the call

Patient Centric Services - Interconnections

RPM CCM Laboratories

Pre-Auth

More Steps incoming

2 1 1 2
Physician
Group Hospital

Patient Centric Services

TCM

Home Health

Care Plan Oversight

Pharmacies
DME

Pre-Auth

More Steps incoming

More Steps incoming

 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Interconnectivity
Let’s walk through the story of Steve, a patient whose journey through the healthcare
system beautifully illustrates how Care Plan Oversight (CPO), Chronic Care
Management (CCM), and Transitional Care Management (TCM) work together to
provide comprehensive, patient-centered care.

Steve’s Heart Surgery and Initial Recovery

After undergoing successful heart surgery, Steve is discharged from the hospital.
However, his journey to full recovery is just beginning. To ensure Steve transitions
smoothly back to his everyday life, his medical team activates Transitional Care
Management (TCM). TCM is designed to bridge the gap between hospital care and
home life, providing Steve with the support he needs during this critical period.
 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Entering Transitional Care Management (TCM)

TCM kicks in immediately after Steve leaves the hospital. A dedicated care
coordinator reaches out to Steve within the first month of his discharge to schedule a
face-to-face visit.

The primary goal of TCM is to prevent any complications that could lead to
rehospitalization within thirty days, ensuring Steve remains healthy and stable as he
adjusts to life at home.
 Increased Episode BIllability

Patient Physician Ancillary Services

Increasing cash flow
Group

Abstracting communication with Physician Groups

Home Health Pharmacies Laboratories DME

Documents to be signed

Start of Care End of calendar month End of Episode Recertification Recert

60 days

485 cert signed Care minutes are alloted 485 cert signed
Claim Submission

Additional Care
coordination is performed
G0179 are filed
G0180 is filed Achieving 30 minutes of care

G0181 is filed

Introducing Care Plan Oversight (CPO)

Given Steve’s severe condition and the complexity of his care, his physician refers him
to a home health provider, bringing Care Plan Oversight (CPO) into the picture. CPO
acts as the central hub for managing Steve’s overall care plan.

A dedicated healthcare provider is assigned to oversee all aspects of Steve’s

treatment, ensuring that every component of his care is coordinated and executed
effectively.
 CCM RPM

Patient Centric Services Physician

Group

Home Health Pharmacies Laboratories DME Hospital

Care Plan Oversight Pre-Auth Pre-Auth TCM

Transitioning from CPO to CCM

Once Steve’s immediate post-surgery needs are adequately managed and he is ready
to step away from home health services, Care Plan Oversight (CPO) concludes its role.
At this point, Chronic Care Management (CCM) begins.

The CCM team takes over to provide continuous support for Steve’s long-term health
needs. This includes regular check-ins, personalized health coaching, and coordinated
care plans that address both his chronic conditions and overall well-being.

"Steve’s journey illustrates how TCM, CPO, and CCM seamlessly collaborate to
provide him with the best care every step of the way, highlighting the importance of
viewing everything holistically because, in essence, everything is interconnected!"
 Until Next time !

Whenever you evaluate something—whether it’s a service or a

concept—aim to see it holistically. Inspired by Taylor Swift’s
words, “Now and then I read the manuscript, but the story isn’t
mine anymore,” it’s important to interpret everything in your own
unique way with a comprehensive understanding.

Don’t become a “mechanical monkey” who simply follows

routines without grasping the underlying reasons. Instead, seek to
understand the “why,” explore your own methods, and embrace
change as a constant.

DID YOU KNOW ?

Carbapenemase-producing organisms
(CPOs) are bacteria that are resistant to
antibiotics called carbapenems