HIPAA Compliant | SOC 2 Certified | NIST Compliant
Care Management
Five Reimbursable Programs.
One Activation Infrastructure.
Medicare reimburses chronic, principal, transitional, remote and annual wellness care, yet most organizations run these programs in silos or not at all. Siloed programs mean duplicate calls, fragmented care and revenue lost at every seam. One activation team, one EHR integration and one methodology connect the programs, so patients get connected care and complete their right next steps between visits.
The Challenge
Your Problem
Medicare’s care management programs were designed to keep patients healthier between visits, reduce avoidable utilization, and generate new revenue for the organizations delivering the care. The economics are clear. The execution is where it falls apart.
You can’t staff five programs with one team
CCM, RPM, PCM, AWV, and TCM each have their own billing codes, documentation requirements, eligibility criteria, and outreach cadences. Building internal capacity across all five means hiring, training, and retaining multiple specialized roles. Most organizations pick one program, run it partially, and leave the rest on the table.
Siloed programs create siloed outcomes
When CCM and RPM don’t talk to each other, patients get duplicate calls, conflicting instructions, and fragmented care. When AWV and TCM operate independently, the data captured in one program never informs the other. Your patients experience the silos even if your org chart says they shouldn’t.
Revenue leaks at every seam
Every care management touchpoint is a billing opportunity, a risk adjustment documentation opportunity, and a quality gap closure opportunity. When programs run separately or don’t run at all, you miss billable minutes, leave RAF codes undocumented, and watch quality measures stay open.
Root Cause
As Healthcare Experts, We See the Deeper Problem
The real problem isn’t that care management is hard to execute. It’s that the model most organizations use was never designed to produce outcomes.
Compliance vs. Activation
Care management without activation is just documentation
Most programs follow the same pattern: call the patient, ask how they’re doing, document the conversation, bill the code. The call produces a compliant record. It doesn’t produce a completed referral, a filled prescription, or a scheduled lab. The patient hangs up and navigates alone.
Duplicated Infrastructure
Five programs running independently cost more than five programs running together
Each program has its own enrollment workflow, documentation template, QA process, and reporting cadence. When they’re separate operations, you duplicate infrastructure, train multiple teams, and create gaps between handoffs.
Uncaptured Value
Your highest acuity patients carry the most uncaptured value
Patients with multiple chronic conditions, recent hospitalizations, and complex social needs are eligible for multiple care management programs simultaneously. They’re also the patients with the most open quality gaps, the most incomplete risk adjustment data, and the highest avoidable utilization risk.
Our Approach
One team. One integration. Five activated programs.
We operate as a dedicated extension of your clinical team, delivering all five CMS reimbursable care management programs through a single operational infrastructure. Same specialists. Same EHR integration. Same activation methodology. No silos. No gaps between programs.
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Activation psychology at every touchpoint
Our specialists are trained in the Motivational Patient Guidance framework. Nine behavioral science techniques that turn care management calls into completed next steps. Not compliance. Activation.
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Single EHR integration, five programs
We document directly in your EHR across CCM, RPM, PCM, AWV, and TCM. One integration. One audit trail. Complete data flowing to every clinician who treats the patient.
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White labeled under your brand
Patients experience our team as your team. Consistent voice, your protocols, your escalation paths. No visible seams between programs or between our team and yours.
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Connected patient journeys, not siloed programs
A patient who discharges from the hospital starts TCM. When the 30 day window closes, they transition to CCM. Their remote monitoring data from RPM informs every CCM call. One relationship. Five revenue streams.
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Full billing capture across all codes
We manage eligibility, enrollment, outreach, documentation, and billing across every applicable CPT code. No billable minutes left uncaptured.
Five Reimbursable Programs
Connected care management across every stage of the patient journey
We deliver all five CMS reimbursable care management programs through a single team and a single EHR integration.
Connected Activation
The patient journey, not the billing code, drives the model
A patient with heart failure and diabetes is discharged from the hospital. Here’s how our connected infrastructure activates them across every stage.
1
Days 1 – 2
TCM Outreach
Confirms discharge instructions, medications, and follow up appointments. Resolves transportation and access barriers during the call.
2
Days 3–30
TCM + RPM
Ongoing TCM management. Remote monitoring tracks weight, blood pressure, and blood glucose daily. When readings spike, our team contacts the patient before it becomes an ED visit.
3
Day 31+
CCM + RPM
TCM transitions to CCM. Monthly activation calls continue. RPM data informs every conversation. Barriers are resolved. Next steps are completed.
4
Annual
AWV
The annual wellness visit captures updated ICD-10 codes, strengthening risk adjustment scores and closing quality gaps.
One patient. One relationship. One team. Three active programs generating revenue, closing quality gaps, and preventing avoidable utilization simultaneously.
PROVEN AT SCALE
Results across every care management program we deliver
A large healthcare organization replaced internal triage with Guideway Care. The result: consistent quality, predictable costs, and nearly $1M in projected savings.
$192,060
Projected annual CCM reimbursement (250 patients)
99.4%
Quality KPI pass rate
35%
Fewer readmissions
31%
Higher patient satisfaction
24/7
RN coverage, zero gaps
Ready to capture revenue across every care management program?
Schedule a consultation and see how a single activation infrastructure can deliver CCM, RPM, PCM, AWV, and TCM without adding headcount or complexity.