Service Model

Fully Managed Care Management

We handle everything: patient outreach, monitoring, documentation, compliance, and billing workflows, so your practice can capture care management revenue without hiring dedicated staff.

Care Management Without the Staffing Burden

Most practices know care management programs like CCM, RPM, and APCM represent significant revenue opportunities. But finding, training, and managing care coordinators is expensive and time-consuming. Staff turnover creates gaps in patient care and revenue. And compliance complexity makes many practices hesitant to start.

CareStream Fully Managed service eliminates these barriers. We operate your care management programs end-to-end, using our AI-powered platform and trained care management team to handle everything from patient identification to billing, while your physicians stay focused on what they do best.

The result: Your practice captures care management revenue with minimal physician time investment, no additional headcount, and zero audit anxiety.

How Fully Managed Works

Our comprehensive approach covers every aspect of care management operations:

01

Patient Identification

We continuously analyze your EHR data to identify patients eligible for care management programs based on diagnoses, utilization patterns, and payer rules. No manual chart review required.

02

Patient Enrollment

Our team conducts compliant outreach via phone and SMS to educate patients about their care management benefits and collect required consent. We handle follow-up for patients who don't respond initially.

03

Ongoing Engagement

Enrolled patients receive regular check-ins, medication reminders, health education, and support through AI-assisted conversations. Our team handles everything from routine wellness calls to complex care coordination.

04

Device Management (RPM/RTM)

For patients on RPM or RTM, we handle complete device logistics: ordering, shipping, setup support, troubleshooting, and replacement. Cellular-enabled devices transmit data automatically.

05

Clinical Escalation

Our platform identifies concerning trends and critical readings. Urgent issues are escalated immediately to your clinical team. Non-urgent items are queued for convenient review. You decide the workflow.

06

Documentation

Every patient interaction is documented automatically in compliant format. Care plans are created and updated based on patient status. Notes sync back to your EHR.

07

Compliance Validation

Before any service is billed, our platform validates that all Medicare requirements have been met: time thresholds, documentation completeness, appropriate coding, and patient consent.

08

Billing Support

Compliant claims are generated with proper code selection and supporting documentation. Ready for your billing team or our optional billing service to submit.

What Your Team Handles

While we manage day-to-day operations, your involvement ensures clinical quality and patient trust:

  • Monthly reviews: Brief review of patient summaries and care plan recommendations (typically 5–10 minutes per patient per month)
  • Clinical escalations: Address urgent clinical concerns identified by our team
  • Enrollment support: Introduce programs to patients during visits when appropriate (significantly improves enrollment rates)
  • Care plan approval: Sign off on care plans as the billing provider

Shared enrollment: Enrollment works best when practices participate directly. While we handle bulk outreach, patients enroll faster and stay engaged longer when their provider introduces the program. This shared approach maximizes revenue without increasing staff burden.

Programs We Manage

Our Fully Managed service supports the complete suite of Medicare care management programs:

APCM
Advanced Primary Care Management
CCM
Chronic Care Management
RPM
Remote Patient Monitoring
RTM
Remote Therapeutic Monitoring
PCM
Principal Care Management
TCM
Transitional Care Management
AWV
Annual Wellness Visit
BHI
Behavioral Health Integration

Why Practices Choose Fully Managed

No hiring required

Avoid the cost and complexity of recruiting care coordinators.

Immediate scale

Enroll hundreds of patients without building internal capacity.

Compliance confidence

Every service validated before billing. Zero audit anxiety.

Predictable revenue

Consistent monthly Medicare reimbursement you can count on.

Better outcomes

Patients receive consistent, proactive care between visits.

Focus on practice

Your providers stay focused on clinical care, not paperwork.

Everything Included

Every CareStream engagement covers the full operational layer — nothing is left to your team to figure out.

CapabilityFully Managed
Patient identification
Enrollment outreach
Ongoing patient engagement
Device management (RPM/RTM)
Documentation & care plans
Compliance validation
Billing workflow support
Dedicated care team

Launch Care Management Without Hiring

Join practices capturing predictable monthly Medicare revenue with CareStream Fully Managed service.

Get Started