Workflow GuideSolo Practices

Solo Practice Chronic Care Monthly Check-In Workflow

Streamline chronic care management in your solo practice with this AI-driven monthly check-in workflow. Maximize APCM revenue without hiring staff.

For solo practitioners, managing chronic care monthly check-ins manually is nearly impossible without dedicated staff. This workflow leverages AI-powered call handling to automate patient outreach, data collection, and documentation, allowing solo doctors to meet APCM requirements and capture significant revenue without increasing their personal workload or hiring new employees.

The Challenge

Solo doctors often skip chronic care check-ins because they lack the care coordination staff to spend 20 minutes per patient, resulting in missed clinical goals and over $150,000 in lost annual APCM revenue that large groups are already capturing.

Step-by-Step Workflow

1

Automated Patient Identification

AI scans your EHR to identify Medicare patients with two or more chronic conditions eligible for APCM, creating a monthly outreach queue without manual physician filtering or data entry.

Best Practices
  • Sync your EHR weekly to ensure new diagnoses are captured
Common Pitfalls
  • Manually searching for patients in a spreadsheet
2

AI-Driven Outreach & Engagement

The AI system initiates the monthly check-in call, using natural language to assess patient status, medication adherence, and any new symptoms or social determinants of health (SDOH).

Best Practices
  • Customize the AI voice to sound familiar to your patient base
Common Pitfalls
  • Using cold-call scripts that feel impersonal
3

Clinical Data Capture & Time Tracking

During the call, the AI captures structured data regarding health goals and barriers, ensuring the 20-minute interaction requirement is met and documented for billing compliance.

Best Practices
  • Ensure the AI asks about medication refills to prevent gaps
Common Pitfalls
  • Failing to document the exact duration of the care call
4

Physician Alert & Red Flag Review

If the AI detects a clinical decline or urgent symptom, it triggers an immediate alert to the solo physician, while routine check-ins are summarized for a quick end-of-day sign-off.

Best Practices
  • Set specific parameters for what constitutes an urgent alert
Common Pitfalls
  • Ignoring AI summaries until the end of the month
5

Automated Documentation Entry

The AI populates the patient record with a detailed encounter note, mapping the conversation to specific APCM quality metrics and time-stamping the interaction for audit readiness.

Best Practices
  • Review the AI's clinical notes for accuracy during the first week
Common Pitfalls
  • Double-entering data from the call into the EHR
6

Billing Code Generation & Submission

Once the monthly requirement is met, the system flags the account for CPT 99490 or relevant APCM codes, ready for the physician to submit as the billing entity.

Best Practices
  • Batch your billing submissions at the end of every month
Common Pitfalls
  • Forgetting to bill for the non-face-to-face time captured by AI

Expected Outcomes

1

Capture $150k+ in annual APCM revenue

2

Zero additional staff hiring required

3

100% compliance with Medicare documentation

4

Improved patient medication adherence

5

Reduced physician administrative time by 90%

6

Enhanced patient satisfaction through regular contact

Frequently Asked Questions

Yes. As the billing entity, you can use AI-powered solutions to perform the care coordination tasks under your general supervision, satisfying Medicare's incident-to billing requirements.

Most solo doctors spend less than 15 minutes a day reviewing the AI-generated summaries and signing off on completed check-ins that occurred while they were seeing other patients.

Absolutely. Our system uses encrypted, HIPAA-compliant communication channels and integrates securely with your existing EHR to protect patient data and ensure solo practice compliance.

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Solo Practice Chronic Care Monthly Check-In Workflow | Tile Health