We at MetaPhy know how important the relationship is between provider and patient. These
relationships are also critically important to the success of the Chronic Care Management (CCM)
program, as our services are done under the provider’s general supervision. As such, it is essential
that the provider be involved in the virtual care that is being provided to patients on their behalf.

Please click below to see a short animated video that outlines the provider’s role in our CCM program.


How do I let my patients know about the CCM program?

Give your Medicare and Medicare Advantage patients a flyer/brochure (provided to your office by MetaPhy) and let them know that if they qualify, a Care Coordinator will be calling to tell them more about the program – it’s that simple!

How do I send patients to MetaPhy that I want enrolled in the CCM program?

Care Coordinators are set up as users in your EMR, so you may send us direct patient referrals via EMR task/message. Our Care Coordinators will be reaching out to all of your qualifying Medicare patients via a letter and follow-up phone call letting them know about the program, but sending them a message via the EMR will result in a much more timely outreach.

How do I know which of my patients are enrolled in CCM?

Monthly care plans (PDF documents) for each of your active CCM patients will be uploaded to the patients’ charts for your review on a monthly basis.

Do I have to sign my patients’ care plans each month?

There is no documented signature required by Medicare for CCM services; however, if these
services are being billed under your general supervision, the initial care plan must be signed
by the provider, as well as when any significant changes are made to the care plan. We recommend signing care plans each month as best practice.

What if I want to make changes to the care/advice that is being provided to a patient?

Just let us know! The CCM program is being done under your general supervision, so we will follow any direction that you provide to us.

What if there is a patient enrolled that I don’t think is appropriate for the CCM program?

Just let us know! The CCM program is being done under your general supervision, so we can easily unenroll patients if you do not think they should be in the program, for whatever reason.

Do I have to see my patients each year in order for them to stay in the CCM program?

There is no Medicare requirement for patients to “re-qualify” for CCM after their initial
qualifying visit. Medicare states that patients should be seen by their provider on a “regular”
basis, but “regular” is not defined. As such, we recommend seeing your active CCM patients
at least once annually as best practice.