ACO Chronic Care Patient Enrollment Checklist

Ensure the beneficiary is currently attributed to the ACO through CMS MSSP assignment rules to maximize shared savings potential.

Utilize claims data to identify patients with two or more chronic conditions that qualify for APCM or CCM reimbursement.

Review HCC scores to prioritize enrollment for patients where chronic care management will have the highest impact on total cost of care.

Identify patients who have outstanding quality measures in the Group Practice Reporting Option to align enrollment with quality bonuses.

Focus enrollment efforts on patients with frequent ED visits or hospitalizations to reduce the ACO's total spend.

Confirm the patient is actively seeing a participating provider within the ACO network for appropriate care coordination.

Use Tile Healthcare AI to conduct high-volume enrollment calls, reducing the administrative burden on clinical staff.

Program AI to explain the benefits of chronic care management and the lack of copay for many ACO-aligned programs.

Use automated workflows to capture and document patient consent for APCM services, ensuring compliance with CMS documentation rules.

Monitor AI call metrics to identify which patient cohorts are most responsive to enrollment invitations across the network.

Trigger AI calls to patients who missed their initial care planning appointment to maintain high enrollment rates.

Ensure outreach is conducted in the patient's preferred language to improve health equity and enrollment diversity.

Implement a single dashboard to monitor enrollment progress across all participating practice sites in the ACO.

Distribute uniform APCM care plan templates to all providers to ensure consistent documentation for CMS audits.

Coordinate enrollment outreach with Annual Wellness Visit scheduling to capture both revenue streams simultaneously.

Track how APCM enrollment correlates with the closure of quality measures like HbA1c control and blood pressure management.

Regularly review enrolled patient records to ensure 20 minutes of non-face-to-face care is being logged correctly.

Use enrollment data to forecast the reduction in total cost of care and potential shared savings distributions.