FAQ

Your practice has partnered with MetaPhy Health to implement a telehealth-based CCM program.

This program will focus on GI-related chronic conditions, including Non-Alcoholic Fatty Liver Disease (NAFLD) and the underlying Metabolic Syndrome-related conditions that are increasing the risk for NAFLD or contributing to the progression of the disease, as well as other GI-specific conditions such as IBS, IBD and GERD.

MetaPhy’s Virtual Care Team (VCT) will be remotely managing these patients for as long as they would like to stay in the program and/or for as long as they still qualify. The VCT is made up of MA’s, LPN’s, RN’s, a PA, a Registered Dietician, an Exercise Physiologist, and a Director of Patient Experience, who are all located in our Virtual Care Center in Nashville, TN.

You will have at least one primary Telehealth Care Coordinator (TCC) assigned to your practice, as well as additional support staff.

By utilizing a telehealth-based platform (phone calls, text messages, emails, etc.), the VCT will help keep patients on track in between office visits using a combination of accountability, educational, and motivational tools (i.e. diet, exercise, nutrition counseling, lifestyle coaching, medication management, etc.).

The TCC will do an initial health assessment in order to develop a personalized care plan based on the patient’s specific conditions, medical history, health-related goals, challenges, etc., which they will work from and update each month. This program also includes our Remote Patient Monitoring (RPM) service for qualified patients, which provides the patient with a digital scale at no additional cost that will electronically transmit their health data straight to their Care Coordinator.

1. Patients must have Medicare (or a Medicare advantage plan) as their primary insurance
   
   
2. Two or more chronic conditions
   
   
3. Have been seen by their provider (office or telehealth visit) within the last 12 months.

If a patient has Medicare (or a Medicare advantage plan) as their primary insurance, we will bill their insurance(s), so there should be no out of pocket cost to the patient. If a patient does not have secondary coverage, a recent OIG policy allows providers to waive any patient responsibility for telehealth services (copays, deductibles, etc.). This way, more patients will stay in the program.

There is absolutely no obligation to stay in the program, so patients can opt out at any time for any reason with no penalty.

Please let us know if/when you have a patient who would like to unenroll, and we will handle ASAP.

Verbal consent is obtained prior to enrolling, which is documented on each patient’s initial care plan.

You may reach out to MetaPhy’s VP of Program Operations, Lisa Harris, at any time with questions or concerns – lharris@metaphyhealth.com or 615-434-2703.

MetaPhy works as an extension of your practice. We reach out to patients on behalf of your practice (i.e. send letters out on your letterhead, call from a local phone number, and communicate with patients via the email nurses@mycarecoordinator.com), so the patients know nothing about MetaPhy as a separate company.

The program brings new lines of revenue, backed by Medicare-approved programs focused on targeted populations, to medical practices at little-to-no risk by offering remote, technology-enabled products and services such as Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) services.

The MetaPhy team will handle the majority of program logistics remotely, but the parts of the program that we will need help with from the practice staff include:

• Occasional Patient Questions – You may receive patient calls from time to time with questions about the program, so please route those calls back to our Care Coordinator. All of our outreach materials list phone numbers for our TCCs, not the practice, so calls to the practice should be minimal.
  
  
• Program Awareness & Encouragement – Let your patients know about the program, give them a flyer, and encourage them to call the Care Coordinator to learn more.
  
  
• Monthly Billing – MetaPhy will provide your practice's billing department with a monthly billing worksheet that lists each patient we helped manage with the corresponding CPT codes that need to be billed. Please make sure to let us know ASAP if you receive any denials so we can investigate and unenroll the patient if need be.
  
  
• Monthly Care Plan Review – MetaPhy will upload patients’ care plans to their charts in your EMR so that providers can then review those care plans on a monthly basis.

The program has very little costs to the practice. We partner with your organization and charge a set fee for the approved CMS codes. The practice is provided a billing file that is sent to Medicare and MetaPhy will invoice the practice for the contracted fees associated with each bill.

Care Coordinators will reach out to eligible patients to explain CCM/RPM services and their benefits. If patients express interest, Care Coordinators will enroll them in the relevant programs.

• COORDINATION OF CARE
• HEALTH COACHING (DIET, EXERCISE)
• GOAL SETTING
• MOTIVATION AND EMPOWERMENT TO SELF-MANAGE AND ACHIEVE BEST OUTCOMES
• EDUCATION ABOUT THE CONDITIONS AND CARE PLAN ACTION STEPS
• MEDICATION ADHERENCE TRACKING
• LIFESTYLE CHANGES AND HEALTHY HABIT DEVELOPMENT
• COACHING ON MANAGING STRESS AND ANXIETY
• CONNECTING TO RELEVANT COMMUNITY RESOURCES
• ASSISTING AND ADVOCATING FOR THE PATIENT IN VARIOUS CARE SETTINGS
• SERVING AS THE LIAISON BETWEEN THE PATIENT AND PRACTICE OR OTHER CARE TEAM MEMBERS

Any outreach to the patient is white labeled under the physician and/or the practice to maintain the patient’s engagement and to serve as the extension of the medical practice. Our goal is to enable the physician to provide care beyond the face-to-face encounters and for the patient to perceive a continuity of care while feeling cared for and supported.

The CCM/RPM services are delivered by Medical Assistants (MA) and Licensed Practical Nurses (LPN), under the oversight and supervision of Registered Nurses (RN), who are also involved in the care delivery.

MetaPhy Health is a services company that helps manage gastroenterology patients with chronic diseases on behalf of the physician.

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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!

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.

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.

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.

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.

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.

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.