Complex Care & High-Utilizer Management
Programs for the patients who drive the highest utilization
Avoidable ED visits and readmissions penalize both outcomes and shared-savings performance, visit after visit. We build the programs for the patients who need the most coordinated support: identifying top utilizers, a response clock after every ED visit and discharge, intensive care management and the social needs work behind it.
- 48-hour post-ED / inpatient outreach
- TCM: 2 business days, 7 and 14 days
- CCM enrollment and SDOH workflows
Who it's for
Built for the organizations that carry this work
Practices with a high-need panel
Primary care practices where a small group of patients accounts for most admissions, ED visits and staff time.
ACOs and risk-bearing entities
MSSP, ACO REACH and Medicare Advantage networks where utilization decides shared savings.
Care management programs
Existing CCM or care coordination teams that need a tighter response clock and clearer roles.
Institutions and health systems
Hospital-affiliated practices aligning discharge, follow-up and community referral across settings.
What we do
What you receive
- 01
Top-utilizer identification
Patients ranked by admissions, ED visits and risk, refreshed regularly, with a named care coordinator for each.
- 02
High-utilizer intensive care management
Individualized care plans with structured follow-up for your top utilizers.
- 03
Post-discharge and post-ED response clock
Outreach within 48 hours of an ED visit or inpatient stay, and TCM workflows built around the two-business-day contact and the 7- and 14-day follow-up.
- 04
CCM enrollment
CCM optimization for eligible high-risk patients: clinically right and billable, with consent, care plans and documentation in place.
- 05
SDOH screening and community referral
Social needs screening workflows for complex populations, with referral and closed-loop follow-up.
- 06
Readmission and avoidable ED reduction
Utilization reduction tied directly to operational care management processes, tracked as readmission rate and ED visits per 1,000.
How it works
The response clock we build into your operations
Every ED visit and discharge starts the same clock, so follow-up never depends on someone remembering.
- 148 hours
Post-ED / inpatient outreach
Outreach to high utilizers after an ED visit or inpatient stay: symptoms, medications, appointments and barriers.
- 22 business days
TCM interactive contact
Contact with the discharged patient or caregiver within two business days of discharge.
- 37 days
First TCM follow-up
Face-to-face visit within 7 days for high-complexity transitions, with medication reconciliation.
- 414 days
Second follow-up checkpoint
Face-to-face visit within 14 days for moderate-complexity transitions, and a check that the care plan is working.
TCM timing follows Medicare's requirements for 99495 (moderate complexity, visit within 14 days) and 99496 (high complexity, visit within 7 days).
Program facts
Codes, requirements and rules
Care management programs that fund the work
For the same patient and month, these programs interact. We set up a monthly sort so each patient is in the program that matches the work delivered.
Transitional Care Management
- Codes
- 99495, 99496
- Fits when
- A patient has been discharged and the practice makes the 2-business-day contact and the 7- or 14-day visit.
Chronic Care Management
- Codes
- 99490, 99439, 99487, 99489, 99491
- Fits when
- Two or more chronic conditions and documented monthly care management time.
Principal Care Management
- Codes
- 99424–99427
- Fits when
- Care management focused on a single complex chronic condition.
Advanced Primary Care Management
- Codes
- G0556–G0558
- Fits when
- The practice is the continuing focal point of primary care; no monthly time threshold. Cannot be billed with CCM, PCM or TCM by the same practitioner in the same month.
Billing rules are Medicare fee-for-service; Medicare Advantage plans may differ.
What we track with you
- Readmission rate
- ED visits per 1,000
- Outreach completed within 48 hours of an ED visit or discharge
- TCM contact within 2 business days and visit within 7 or 14 days
- CCM enrollment among eligible high-risk patients
- SDOH screens completed and referrals closed
FAQs
Common questions
How do you decide who is a high utilizer?
From your own data: admissions, ED visits, risk tier and diagnoses, refreshed on a regular schedule. The list is reviewed with your clinicians so it reflects patients the team can actually help.
Can TCM and APCM be billed in the same month?
Not by the same practitioner for the same patient. When a discharge happens mid-month, bill after month-end so the month can go to TCM; APCM resumes the next month.
How quickly do we need to reach a discharged patient?
For TCM, an interactive contact within two business days of discharge, then a face-to-face visit within 7 days (high complexity) or 14 days (moderate complexity). We add a 48-hour outreach for high utilizers after any ED visit or inpatient stay.
Do you provide the care managers?
We design the program and train your team. Where you need it, we can also run program operations with your staff; the engagement level is agreed up front.
Ready to simplify the complex?
Let’s look at your program together.
A consultation is a working conversation about your panel, payers and EHR, and whether this service fits. Please do not send patient information.
Related services
Chronic & Principal Care Management (CCM / PCM)
Care plans, monthly time-based care management and documentation.
Learn moreAdvanced Primary Care Management (APCM)
G0556–G0558 monthly care management, levels by complexity.
Learn moreACO & Value-Based Performance Enablement
Tie quality, risk and utilization work to Stars, withholds and shared savings.
Learn more