Proactively Engaging Patients for Better Health Outcomes

Chronic Care Management Solutions

Elevate Your Patients Care and Practice Revenue

Centro HealthCare’s Chronic Care Management services will help you meet the requirements of Medicare’s new chronic care management CPT Code 99490 to maximize your monthly revenue allowing you to focus on your Patient care. Centro Healthcare fulfills the requirements of the CMS program, meets the day-to-day obligations of clinical documentation, coding and revenue cycle management to guarantee you maximum reimbursements.

Our Chronic Care Management Services

Centro Healthcare acts as an extension to your practice to ensure the highest quality of care, drive higher patient engagement and help your practice develop a new revenue stream through our personalized care services.

EHR Integration & Customization

We provide a smooth and rapid EHR integration and customization process which will enable you to access real-time data and efficiently monitor your enrolled patients

Eligible Patients Identification

We quickly identify your eligible patients who have 2 or more chronic conditions and meet Medicare’s Chronic Care Management requirements

Patient Outreach

We reach out to your patients and educate them about the value of the program, obtain their informed consent, and document it in their medical record

Patient-Centered Care Plan

We provide a regularly updated and customized health summary and care plan that includes all the information on the patient’s health conditions

Patient Engagement

We engage your patients to provide them with ongoing care monitoring and regular assessments of their medical needs to improve their health and overall satisfaction

Streamline Patients Enrollment

We help you maximize your revenue through identifying and enrolling new patients to increase your Chronic Care Management enrollment

24/7 Care Support

We ensure the best patient-experience by providing them with 24/7 access to our licensed and certified medical personnel to address their urgent chronic care needs

Monthly Care Coordination

We successfully contact each eligible patient every month to conduct at least 20 minutes of non-face-to-face care to help them manage their chronic conditions through assessing their health needs and conducting medication reconciliation

EHR Documentation

We document and track the time spent on CCM from within the patient’s chart into their EHR to provide you with comprehensive CCM documentation for your continued access and review


We process all completed document forms and properly track every encounter to provide your staff with an auditable report at the end of each month, so billing for CPT 99490 is easier and 100% Medicare compliant

Benefits of Outsourcing Chronic Care Managment (CCM)

Our Turn-Key Solutions Will Help You:

Increase Revenue Streams

Earn new recurring revenue and create a new profit center through Medicare’s CCM bill code 99490 while improving patients’ clinical outcome.


We customize patient-centered care plans and preventative care services to your specifications to reinforce compliant behaviors and medication management to help patients stay on track.


We ensure better patient experience and expand patient engagement and satisfaction through our 24/7 care support


Stay in compliance with CMS’ requirements and guidelines through our comprehensive auditable reports


We create more efficient workflows which improve your staff’s workload balance and reduce the time spent on non-clinical activities.

Meet MACRA’s Quality Measures (MIPS & APM)

MACRA’s Quality Payment Program provides you new tools and resources to help you give your patients the best possible care. CCM participation hits 33 measures in the MIPS Quality category including 22 high priority measures. If you choose to be part of an Advanced APM, through Medicare Part B you could earn an incentive payment for participating in an innovative payment model. It also fulfills some Clinical Practice Improvement Activities (CPIAs), addresses cost/resource use by decreasing avoidable interventions and encourages the use of EHRs.

Are You Ready To Simplify Your CCM Workflow?

Our Workflow

Centro HealthCare performs this monthly service for you to get healthier patients and monthly recurring payments without hiring additional full-time staff members nor any changes in your current workflow. And with absolutely no additional administrative burdens to your practice.


  • EHR integration
  • Extract Patient’s data


Identify all eligible patients with 2 or more chronic conditions


  • Outreach to Patients
  • Educate them on the benefits of CCM
  • Acquire signed consent forms
  • Enroll them in the program


  • Explore care gaps
  • Build evidence-based personalized care plans
  • Provide 20+ minutes of coordinated care
  • Follow up and update health summary


  • Track time spent in all check-in calls
  • Document data on EHR
  • Create auditable report


  • Provide billing documents
  • Bill monthly for Patients that meet the 20+ minutes of care coordination

Achieve the Triple Aim through CCM

Reducing the Per Capita Cost of Healthcare

Managing and improving chronic conditions for Medicare’s patient population is an essential step to achieving a high quality of care through optimized performance. It upholds the healthcare industry’s pursuit of the Triple Aim which can potentially lead to better models for providing healthcare.

Supporting the Patients

  • Giving patients the support they need with a dedicated care manager and unique plan that they are more likely to follow because of individualized instructions
  • Providing patients with a care coordinator that closely monitors their health.

Strengthen care management
Developing meaningful relationships between providers and patients to enhance their wellness

  • Manage Risks & Transitions:
    Delivering improved medical outcomes and quantifiable savings through patient care management, tracking, and cost containment of high-risk patient cases
  • Improved patient self-management:
    Reinforcing compliant behaviors and medication management helps patients stay on track.
  • Proactive Management:
    Proactively manage patient’s health rather than only treating disease and illness.
  • Cost control
    Research shows that, on average, costs for patients with uncoordinated care were 75% higher than matched patients whose care was coordinated
  • Fewer hospital admissions and readmissions
    A recent study shows patients who thoroughly understand their after-hospital care instructions are 30% less likely to be readmitted or go to the emergency department.

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