With payers covering more than 165 million people pledging ACCESS-aligned payments by 2028, digitally-enabled chronic care is becoming a financial opportunity as much as a clinical one. Start by confirming Medicare eligibility, then build your technology, staffing, and documentation workflows so you can bill for the between-visit work your team already does and track ROI from day one.

Chronic care management (CCM) is becoming increasingly digital—and Medicare policy is helping accelerate the shift. In July 2026, more than 150 healthcare organizations began participating in the CMS Innovation Center’s Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, which emphasizes the use of technology to improve outcomes for patients with common chronic conditions.

The model reflects a broader CMS push toward digitally-enabled chronic care, including remote monitoring, digital care management platforms, and data-driven approaches that help providers identify needs and engage patients beyond the walls of the practice. For practices, the message is clear: Technology is becoming an increasingly important part of how chronic care is coordinated, delivered, and measured. Building a digitally-enabled chronic care management program now can help practices strengthen care between visits, improve efficiency, and prepare for a healthcare environment that increasingly rewards continuous, connected chronic care.

Digitally-enabled chronic care uses technology and health data to help care teams continuously monitor, engage, and coordinate care for patients with chronic conditions — both during and between office visits. This enables earlier and more proactive intervention. In contrast, in a traditional model, chronic care tends to revolve around scheduled, in-person encounters, with relatively limited visibility into what happens to the patient between visits. Clinicians often rely on information collected during appointments, and patients may need to initiate contact when symptoms worsen or questions arise. 

Keep in mind: For many practices, digitally-enabled chronic care doesn't replace traditional chronic care — it fills the gaps between in-person encounters. A patient might still see their physician regularly in the office while digital tools help the care team monitor their condition, communicate with them, coordinate services, and respond to emerging needs between visits.

Digitally-enabled chronic care matters for practices now because the way chronic conditions are managed — and increasingly paid for — is shifting from episodic, visit-based care toward continuous, technology-supported care focused on measurable outcomes. Practices that don't have the infrastructure and workflows to support ongoing chronic care may not only miss opportunities to improve patient outcomes but also leave revenue on the table. By identifying eligible patients, capturing reimbursable care management activities, and preparing for emerging value-based payment models, practices can turn chronic care management into both a clinical and financial opportunity.

The CMS ACCESS Model is a particularly visible sign of the shift toward digitally-enabled chronic care. Launched in July 2026, ACCESS tests recurring, outcome-aligned payments for technology-supported chronic care and is specifically designed to complement traditional physician care. CMS also recently expanded the model with additional chronic-condition tracks beginning in 2027. In addition, payers representing more than 165 million people across Medicare Advantage, Medicaid, and commercial insurance have pledged to offer payment arrangements aligned with core ACCESS principles by 2028. 

As CMS and other payers place greater emphasis on technology-supported, outcomes-based care, practices that build the right technology, workflows, and care coordination processes now may be better positioned to keep patients connected between visits and adapt to emerging value-based payment opportunities.

Patients with multiple or complex conditions struggle to access the ongoing care they need. A 2026 KFF survey found that 36% of adults ages 18–64 with three or more health conditions skipped or delayed care because of cost, while 25% could not find a provider with available appointments. Among those who postponed care, 27% said their health worsened as a result. By extending chronic care beyond the office through remote monitoring, virtual communication, and other digital tools, practices have an opportunity to maintain stronger connections with patients, identify needs earlier, and potentially address some barriers to timely care. In addition, stronger between-visit engagement may also improve care plan adherence and patient retention while helping practices succeed under value-based arrangements that increasingly reward outcomes and ongoing chronic disease management.

Adding digital tools does not change the underlying rules for billing Medicare for chronic care management. Before enrolling patients, practices need to verify that they meet the applicable eligibility criteria and understand billing requirements. 

Eligible CCM patients have multiple (2 or more) chronic conditions expected to last at least 12 months or until the patient’s death or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. 

Use EHR data to create a preliminary list of patients who may qualify for Medicare CCM, rather than identifying them manually during individual visits. Consider these steps:

Before providing and billing for digitally-enabled chronic care, the practice must obtain the patient’s written or verbal consent and document it in the medical record. For patient consent, practices must inform the patient of the following and document same in their medical record:

For new patients or patients who have not been seen by the billing practitioner within the prior year, CMS also requires an initiating visit before CCM begins. That visit can occur as part of a comprehensive E/M service, Annual Wellness Visit, or Initial Preventive Physical Exam.

Documentation to support medical necessity must include patient consent as well as electronic recording of patient health information (i.e., the patient’s demographics, problems, medications, and medication allergies), comprehensive care plan, and medical decision making. Note that complex CCM services require and include moderate- to high-complexity medical decision-making by the physician or other billing practitioner.

Remember: diagnosis codes alone don't tell the whole story. Instead, ensure documentation includes the following:

Choosing a tech stack means identifying the combination of tools needed to support digitally-enabled chronic care, such as the EHR, care management platform, remote monitoring technology, patient communication tools, and analytics. Practices should prioritize solutions that integrate with existing systems, support efficient workflows and data sharing, protect patient information, and give care teams actionable data without adding unnecessary administrative burden.

When evaluating EHR integration for a digitally-enabled chronic care management program, practices should look for bidirectional interoperability that allows RPM data to flow into the EHR while relevant clinical and demographic data flows back to the RPM platform. Also look for real-time or timely data exchange, configurable alerts and thresholds, integration into existing clinician workflows, automated documentation, and the ability to distinguish actionable information from data that could contribute to alert fatigue.

When choosing RPM devices and vendors, look for clinically appropriate, easy-to-use devices that reliably capture and transmit accurate patient data with minimal burden on patients and staff. Evaluate whether the vendor:

Also consider patient support and training, device connectivity, workflow fit, scalability, vendor responsiveness, and total cost as the program grows.

When deciding whether to build or buy chronic care management software, consider upfront and ongoing costs, implementation time, EHR integration, customization needs, scalability, security, compliance, and available IT resources. The same is true when deciding whether to build or buy remote patient monitoring software; however, practices must also consider device compatibility, bidirectional data exchange, alert management, and patient usability. In general, building offers greater control but requires more technical expertise and maintenance, while buying can accelerate deployment and provide ongoing vendor support but may offer less flexibility and involve recurring fees.

Something to consider: The best chronic care management software complements the EHR by adding specialized tools for patient enrollment, care-management workflows, and population-level monitoring.

For a digitally-enabled chronic care management program, upfront technology costs may include a care management platform, RPM devices, EHR integration, patient communication tools, analytics capabilities, and the infrastructure needed to securely exchange and manage patient data. Practices should also budget for implementation, configuration, device provisioning, staff training, workflow redesign, and patient onboarding, not just the price of the technology itself.

A clear staffing and escalation model ensures the right team members monitor patient data, perform CCM activities, respond to alerts, and escalate clinical concerns to the appropriate clinician at the right time. Defining these responsibilities upfront helps:

A digitally-enabled chronic care management program works best when each care team member has a clearly defined role across the entire patient journey, not just when an abnormal reading occurs. Define responsibilities based on applicable Medicare supervision and billing requirements, state scope-of-practice rules, and the practice's staffing model.

For smaller practices, one person may fill several of these roles. The important step is to define who owns enrollment, care planning, routine outreach, monitoring, documentation, billing, and escalation—and build those responsibilities into the digital workflow so tasks don't fall through the cracks.

When setting escalation thresholds for abnormal readings, practices should avoid a one-size-fits-all approach. 

In addition, practices should establish role-based escalation protocols before monitoring begins.

Assess staff capacity, skill mix, and the time required for each activity before determining how responsibilities will be distributed. Technology can help ease that burden by automating routine tasks, prioritizing patients who need attention, streamlining documentation, and bringing actionable information into existing workflows. However, practices still need adequate staff to engage patients, review information, and respond when clinical intervention is needed. 

Also keep in mind that CCM requires practices to provide patients with 24/7 access to a physician, other qualified practitioner, or clinical staff for urgent chronic care needs. Practices must also designate a care team member who maintains regular contact with the patient and is available for routine appointments. Patients and caregivers should have multiple ways to communicate with the care team, including phone, secure messaging, and a patient portal.

Accurately capturing time, documentation, and billing is essential to ensuring the work performed through a CCM program translates into compliant reimbursement — and the right EHR can help.

CPT code 99490 denotes the first 20 minutes per calendar month of CCM services provided by clinical staff under practitioner supervision. However, there are also a variety of other CCM codes to consider.

Remote patient monitoring (RPM) is one of the core technologies behind digitally-enabled chronic care. It provides physiologic data from connected medical devices, giving care teams greater visibility into a patient's condition between visits. When integrated into a digitally-enabled chronic care program, RPM data can help teams identify concerning trends, prioritize outreach, intervene earlier, and make more informed care-management decisions.

Historically, Medicare required at least 16 days of data in a 30-day period to bill RPM; however, beginning in 2026, new RPM coding accommodates shorter-duration monitoring periods. 

The biggest documentation risk in digitally-enabled chronic care is treating digital activity as documentation in itself. A stream of readings, alerts, messages, or timestamps doesn't necessarily demonstrate a billable service; practices need to document what the care team did with that information and how it supported the patient's ongoing care. Here are some additional documentation gaps that can trigger denials or audits and how the right EHR and billing software can help.

Once a digitally-enabled chronic care program is up and running, practices need to determine whether it is financially sustainable, clinically effective, and valuable to patients and payers.

To calculate breakeven per enrolled patient, practices should determine the average monthly revenue generated per patient and compare it with the per-patient cost of technology, devices, staff time, vendor fees, and other program expenses. They can then calculate how many enrolled—and actively participating—patients are needed for program revenue to cover total fixed and variable costs.

Practices should select clinical outcome metrics that align with the chronic conditions they manage, such as blood pressure or glucose control, medication adherence, symptom improvement, hospitalizations, and emergency department visits. Track these measures over time and compare them with baseline data to determine whether digitally-enabled care is improving patient outcomes and identify opportunities for intervention.

Practices should identify the quality, utilization, cost, and patient outcome measures tied to each value-based contract and build workflows to capture those data consistently. Use dashboards or reports to track performance against contract benchmarks and demonstrate how digitally-enabled chronic care affects outcomes such as:

For example, if a value-based contract rewards improved hypertension control and reduced hospital utilization, the practice could report the percentage of enrolled patients whose blood pressure reached the target range, along with changes in ED visits and hospitalizations. The practice could then compare results before and after enrollment to demonstrate whether digitally-enabled chronic care is contributing to the contract's quality and utilization goals.

Practices should track whether patients enroll, consistently use digital tools or connected devices, transmit required data, and respond to digital outreach, while identifying barriers such as limited technology skills, connectivity, language, or difficulty using devices. Provide simple onboarding, hands-on education, technical support, and alternative ways to participate when appropriate so digital literacy does not become a barrier to effective chronic care.

You’re already coordinating care between visits. The question is whether your EHR captures it. Take Tebra’s self-guided product tour to see how EHR+ tracks care-coordination time, supports your documentation, and carries it through to billing in one system.