Transitional Care Management (TCM) — Subscription. Readmissions ↓, TCM capture ↑
The TCM service by Remote Practice Managers, Inc. streamlines post‑discharge care coordination—helping practices reduce readmissions, improve patient outcomes, and maximize reimbursement through compliant Transitional Care Management billing.
💲 $6,500.00 per month (per practice location)
- Includes patient identification, outreach, workflow integration, compliance support, and monthly dashboards.
- Optional add‑on: $1,500.00 per month for advanced analytics, multilingual patient outreach, and quarterly provider training workshops.
Transitional Care Management (TCM)
Engagement: Subscription | Delivery Time: 2-3 weeks | Tier: Essential
Project Summary: Closes post-discharge gaps and speeds follow-up.
Deliverables
- ADT tracking
- 2-day outreach
- Visit scheduling
ROI Impact: Readmissions ↓, TCM capture ↑
Great For: Primary care & multispecialty
Hospital discharges are one of the most vulnerable points in a patient’s care journey. Without structured follow‑up, patients risk complications, readmissions, and poor outcomes. At the same time, practices often miss out on valuable reimbursement opportunities tied to Transitional Care Management (TCM) services.
The Transitional Care Management (TCM) service provides a turnkey framework to ensure your practice delivers high‑quality post‑discharge care while capturing the full financial value of TCM billing.
What’s Included:
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Patient Identification & Enrollment
- Automated reports flag eligible patients discharged from inpatient or observation stays.
- Outreach protocols to engage patients within the required 2‑day window.
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Care Coordination & Follow‑Up
- Structured phone calls to assess patient status, medication reconciliation, and care needs.
- Scheduling of timely follow‑up visits (within 7–14 days, per CMS requirements).
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Workflow Integration
- Standardized templates and checklists for providers and staff.
- Seamless integration with EHR and scheduling systems.
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Compliance & Documentation
- Guidance on meeting CMS requirements for TCM billing (CPT 99495, 99496).
- Audit‑ready documentation support to protect against compliance risk.
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Revenue Optimization
- Accurate coding and billing workflows to ensure maximum reimbursement.
- Identification of additional billable opportunities (e.g., chronic care management).
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Performance Monitoring
- Dashboards tracking TCM completion rates, readmission reductions, and revenue impact.
- Monthly executive reports with actionable recommendations.
Why It Matters
Every missed TCM opportunity is both a clinical risk and a financial loss. By implementing structured TCM workflows, your practice can reduce costly readmissions, improve patient satisfaction, and capture thousands in additional reimbursement annually. The TCM service transforms post‑discharge care from a compliance burden into a strategic advantage.
🏥 Before & After TCM Snapshot
| Before (Unmanaged Transitions of Care) | After (With TCM Optimization Service) |
|---|---|
| Patients discharged without timely follow‑up | Patients contacted within 2 days and scheduled for follow‑up visits |
| High readmission rates due to poor coordination | Reduced readmissions through structured outreach and care management |
| Missed CMS reimbursement for TCM codes (99495, 99496) | Consistent, compliant billing captures new recurring revenue |
| Manual, inconsistent workflows burden staff | Standardized templates and automated processes streamline operations |
| Providers unaware of patient discharge status | Real‑time alerts and dashboards keep providers informed |
| Documentation gaps create compliance risk | Audit‑ready documentation ensures CMS compliance |
| Leadership lacks visibility into post‑discharge outcomes | Executive reports link TCM performance to financial and clinical results |
🏥 Value Proposition Callout Box – Transitional Care Management (TCM)
Why Choose Transitional Care Management? Because every missed follow‑up after discharge is both a patient safety risk and a lost revenue opportunity.
✅ Reduce Readmissions – Structured outreach and timely follow‑up visits lower costly hospital readmissions. ✅ Capture Post‑Discharge Revenue – Compliant TCM billing (CPT 99495, 99496) ensures your practice is reimbursed for the care you already provide. ✅ Strengthen Patient Trust – Proactive engagement improves satisfaction, continuity of care, and long‑term loyalty.
Result: A turnkey TCM framework that transforms post‑discharge care from a compliance burden into a strategic advantage—improving outcomes, protecting revenue, and enhancing patient relationships.