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Medicare will pay your practice to keep chronically ill patients out of the hospital, so why do most practices leave that money unused? Rachel Yates, a registered nurse and health care executive, joins to explain two reimbursement programs Medicare introduced in 2024, Community Health Integration and Principal Illness Navigation, and why two years later most practices still are not using them. This episode is based on her article “Patients pay when Medicare care coordination codes go unused,” published on KevinMD. You will hear who actually qualifies, the patients you already see every day who keep cycling back through the ED, and how a single missed medication instruction can turn into a preventable readmission. Rachel makes the case that this is clinical care, not a billing add-on, and that the work can be delivered by contracted nurses under your supervision without piling more onto your existing staff. She walks through what a real between-visit coordination relationship looks like and why a 15-minute appointment was never going to fix everything. She lays out who qualifies, why the codes go unused, and the decision every practice now has to make.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Rachel Yates. She is a nurse and health care executive. Today’s KevinMD article is “Patients pay when Medicare care coordination codes go unused.” Rachel, welcome to the show.

Rachel Yates: Thank you so much for having me, Kevin.

Kevin Pho: So let’s start by briefly sharing your story, then we’ll jump right into your KevinMD article.

Rachel Yates: Great, yes. So I’m a registered nurse. I have almost 10 years of experience. I did start health care fairly young. In high school, I got my nursing assistant license and my EMT through the vocational programs that were offered.

When I graduated, I went straight into college and got my BSN, and I started my nursing career in a trauma surgical ICU. Then I spent a lot of my time in virtual nursing remotely. I am finishing up my MSN in executive nurse leadership right now, and I plan to start my DNP this fall.

I believe that you don’t have to wait until you have every credential behind you to actually start building something. So my husband, Savante, and I founded Premier Care Coordination. It’s a nurse-led coordination service, specifically the programs Community Health Integration and Principal Illness Navigation, that we offer to practices.

Kevin Pho: So you wrote this article on KevinMD, “Patients pay when Medicare care coordination codes go unused.” Tell us why you decided to write this article, and then about the article itself for those who didn’t get a chance to read it yet.

Rachel Yates: Yes. So in 2024, CMS introduced two new categories of reimbursement called Community Health Integration and Principal Illness Navigation. These are funded for exactly the kind of patients who would have kept a lot of my ICU patients out of the hospital in the first place. They are reimbursable services that any practice can deliver today for the patients they are already seeing. But two years later, most practices still aren’t using them.

I wrote this piece because I think this is one of the most under-discussed topics in health care right now. Practices have the patients, the funding is there, and the clinical work that would help them is well understood. What’s missing is the operational layer that ties it all together. The thing I really wanted the physicians to hear is that they don’t have to build that layer themselves. They don’t have to hire a whole new team. They don’t have to take their existing staff and pile this on top of everything else they’re already doing, and they don’t have to redesign their workflow. This work can be done by contracted auxiliary personnel under the physician’s supervision, which is how these codes were designed to be delivered.

So a company like ours, Premier Care Coordination, comes in and operates at that layer, so the practices get the clinical benefit and the reimbursement without that extra burden on their team. With my piece here, I really wanted to let facilities know that this isn’t just a billing thing. It’s actually a real part of clinical care. The longer we keep treating coordination like it’s optional, the more patients end up paying for a problem that was never theirs to begin with.

Kevin Pho: So give us an example of a common patient or a common scenario where a physician would use these codes.

Rachel Yates: OK, so there are care coordination companies out there that essentially do documentation. They log the calls, they check the boxes, and they generate the report at the end of the month. What I’m building here at Premier Care Coordination is different. Every patient on our service has a named nurse responsible for them. They’re not in a rotating queue. So when something comes up between visits, for example, a blood pressure trending the wrong way, a missed medication refill, or a new social barrier, that nurse is the one actioning it in real time. They’re not documenting it for someone to review later.

By the time the provider sees that patient at their next visit, the issue is already worked. It’s not just charted. So documentation is only useful if there’s a clinician accountable for acting on that data, and that is what closing the gap really means. We have to continue care between visits. We can’t keep expecting a 15-minute appointment to fix everything.

Kevin Pho: Now, what are some of the reasons why these codes are so underused? Why are physicians overlooking them?

Rachel Yates: I believe the issue here is education. These codes are fairly new. They were released in 2024, and when I speak to practices, a lot of them say, “We already do CCM.” So I have to explain to them that these are expansions from that CCM, offered to the patients you already see.

Kevin Pho: In terms of outcomes, as far as you know, is there any data or studies showing that coordination between hospital visits eventually reduces these patients from going back to the hospital for readmissions?

Rachel Yates: Since these codes are fairly new, there’s not much data on the new codes specifically. But there is substantial evidence going back over a decade showing that care coordination reduces readmissions and improves outcomes for chronically ill patients. So CMS wouldn’t have built these reimbursement structures if the evidence wasn’t strong. The challenge hasn’t been whether it works. It’s been how to deliver it consistently at scale.

Kevin Pho: So give us some stories or case studies of either yourself or other nurses working between physician visits or between hospitalizations. What’s a typical care coordination visit or interaction like?

Rachel Yates: Yes. So at Premier Care Coordination, we really want to be an extension of whatever facility we work with. So we introduce ourselves as an extension of that practice, and we let the patient know that we’re calling from this specific doctor. Throughout the month, we follow up with the patient, making sure that all the social needs they have are met.

The line that we have is open, so we’re not just making sure they get those 60 minutes for the month. They can call whenever they need to. If there’s an emergency or if they forget something, we are here for them. We do go over those 60 minutes if needed. It’s just not specifically set at those 60 minutes. We really want to provide that premier care for those patients.

Kevin Pho: This coordination is primarily done virtually or over the phone. What if someone needs to see the patient, do a house call, for instance, between visits?

Rachel Yates: Yes. So if a patient needs to be seen between visits, we have full access to the provider’s office, so if they need to come in to be seen, we can coordinate that and schedule them an appointment. We also work with some home health agencies, so if a nurse or a nurse practitioner is available, that nurse practitioner can see the patient. Otherwise, we coordinate a way for that patient to get the care they need, depending on the situation.

Kevin Pho: So can you tell us a story of something that you or your team caught from a care coordination standpoint that may have prevented a readmission or prevented a patient from medically deteriorating? What would be an example of something you caught?

Rachel Yates: Yes. An easy one that I remember is medication. A patient had a new medication that was prescribed. I got a phone call that the patient wasn’t sure how to take it. I had them read what was on the bottle, and the patient couldn’t understand the medical wording on how many times a day the medication needed to be taken. So I explained it to the patient. Instead of that patient not taking the medication and causing more health issues, that prevented a readmission or a deterioration in that patient’s health, because I was able to explain and take the time to really educate that patient on how to properly take the medication that the provider prescribed.

Kevin Pho: So I know you have a service where you provide care coordination. What’s the landscape like today? Do most hospital systems and physician practices do their own care coordination? And if so, how much work goes into that versus contracting out to a company like yours?

Rachel Yates: Yes. So right now, if they’re doing care coordination in-house, that is a lot of burden on the staff that already exists. And if they were to add CHI or PIN to their existing staff, it really wouldn’t be possible because of how much documentation is needed. The time requirements with these patients are more than what CCM offers. CCM is about 20 minutes that they need for the month. For CHI and PIN, you need 60 minutes in order for that patient to qualify. So the hospital and staff would not be capable of keeping up with the patients and giving that quality care that is needed.

Kevin Pho: So in general, however much Medicare reimburses for chronic care coordination, is it still a net positive financially for these practices to bill for this cause? Because they still have to pay for contracted services like yours, right?

Rachel Yates: Yes. So the way it works is they get the reimbursement, and if they were to work with contracted auxiliary personnel like our own company, we have certain ways we work with different facilities. But basically, we do a fair market value where they keep a portion of it, because they have the patient panel, and then they would pay the contracted auxiliary personnel.

Kevin Pho: So tell us, in terms of what you see, the future trends as they relate to chronic care coordination. What do you see on the horizon?

Rachel Yates: Yes. So care coordination is one of the areas Medicare has consistently invested in, even when other reimbursements have been cut. The 2024 expansion of CHI and PIN, and the 2026 expansion to mental health counselors as well, these are growth signals, not cut signals. The trend is toward paying for outcomes, and that’s exactly what these codes are designed for.

Kevin Pho: We’re talking to Rachel Yates. She’s a nurse and health care executive. Today’s KevinMD article is “Patients pay when Medicare care coordination codes go unused.” Rachel, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.

Rachel Yates: So if there’s one thing I wanted to leave with the audience, it would be that Medicare has built a real opportunity that most practices are missing right now. It’s not because anyone is doing anything wrong. It’s because the system to actually capture it hasn’t been built into how practices run today.

The patients who qualify for CHI and PIN are patients you already see every single day. They’re the chronically ill ones, the ones with social complexity, the ones who keep ending up in the ED for things that probably could have been prevented if somebody had been checking on them between visits. Medicare actually wants to pay you to keep those patients well, and that’s what these codes were built for.

And the patients you’re missing this for are the ones who need it the most. The patients with dementia whose daughter is trying to figure out a brand-new diagnosis on her own. The patient with COPD who keeps ending up back in the hospital because nobody’s catching things early enough.

You don’t have to build this on your own, and you don’t have to figure it out from scratch either. But you do have to know that these new codes and programs exist, and you do have to decide to do something about it, whether that’s building it internally or partnering with a company like ours that’s already built. Either way, your patients have been waiting on this longer than they should have to.

Kevin Pho: Rachel, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Rachel Yates: Thank you so much for having me, Kevin. It was a real honor.