Getting Paid to Do the Right Thing

Two sentences about combining programs were too broad. The rule that keeps Advanced Primary Care Management (APCM) and Transitional Care Management (TCM) from being billed together for the same patient in the same month binds the one practitioner who furnishes APCM, not the whole practice, so another practitioner can bill TCM when it is medically necessary. In the chapter that models a switch to APCM, the printed text now says so, and the same fix applies to the sentence about giving up TCM and CCM billing. The Principal Illness Navigation rule now adds that one practitioner cannot bill it for two conditions for the same patient. The twelve program fact cards in the online companion at intellectualfrontiers.com were each checked against the 2026 Physician Fee Schedule final rule and current CMS guidance, with the source and date on every card, and they now flag the changes CMS has proposed for 2027 in remote monitoring and advance care planning. A printed copy you already own has the earlier wording; the fact cards are the current reference.

The working tools that run a between-visit care operation moved from seven printed appendices to the online companion at intellectualfrontiers.com, where you can use them on a screen and where the fact cards can be corrected when Medicare rules change. The companion holds the scorecard that produces every between-visit care number by program each month, the questions to ask each role, six one-page worksheets that turn each method into team work, three operating-review agendas that keep the meeting on decisions, the Monday Morning Page you can fill in in fifteen minutes, the completeness checklist, and a fact card for each program to check against current CMS rules. The printed book keeps a short appendix that says where each tool went, and it prints the tools you reach for most on paper: a short Monday Morning Page with room to fill it in, the monthly scorecard listing each measure with one line of definition, and the forty-five-minute monthly review agenda. The full versions, and the fact cards, are online only.

Medicare already pays for the between-visit care most practices deliver, and most practices haven't built the operation that earns the payment. Medicare now pays for chronic care management, transitions after discharge, remote monitoring, behavioral health integration, advance care planning and monthly advanced primary care bundles, and practices collect a small fraction of it because the administrative work is unfunded. This fieldbook is the operating manual for closing that gap. It introduces the Attention Loop, the Capture Ladder, the Administrative Denominator, the Care-Delivery Operating System and Practice Math, and works each through the same practices month after month. You learn to find the between-visit care Medicare already pays for, run the Capture Ladder from eligible to helped, measure administrative minutes per patient-month, decide what software should remember and what only a clinician should decide, and launch one program for one cohort before you scale. It is for practice owners, medical directors and operators.