What could PCMH be worth to your practice each year?
Primary care practices earn PCMH money two ways: payer programs that pay a monthly amount per patient, and care management codes billed to Medicare. Enter your panel and see the yearly gross, the staffing cost and what is left.
Your panel and payer programs
For each payer: how many patients are on your panel, what share of them a PCMH or care management program covers, and the amount that program pays per member per month (PMPM). The PMPM comes from your payer contract or program letter; the placeholders show typical ranges only.
Care management billing (Medicare)
Patients billed per month and the rate you are paid. The rates below approximate Medicare national amounts; edit them to match your locality or your Medicare Advantage contracts.
Staffing and providers
How we calculate this
Every line uses only what you typed. No hidden multipliers.
- Payer program revenue, per payer = empanelled patients × share in a program × PMPM × 12 months.
- Care management billing = patients billed per month × rate, for CCM, APCM and TCM, × 12. The same patient should not be counted under both CCM and APCM in the same month.
- Annual gross = payer program revenue + care management billing.
- Staffing cost = care manager FTE × loaded cost per FTE. Other costs (software, recognition fees, provider time) are not included; add them to the FTE cost if you want a fuller picture.
- Net = gross minus staffing cost. Per provider = divided by the number of providers.
Where NCQA recognition fits
Recognition itself does not pay you. NCQA PCMH recognition is a standard; the money comes from two places that often depend on it.
Payer programs. Many Medicaid programs, Medicare Advantage plans and commercial payers pay a monthly amount per patient, an enhanced fee schedule or shared savings to recognized practices. Terms and amounts differ by state and contract, which is why this calculator asks you for the PMPM instead of assuming one.
Care management codes. CCM, APCM and TCM can be billed by any practice that meets the documentation rules. Recognition is not required, but the workflows recognition asks for (empanelment, care plans, follow-up after discharge) are the same ones that make these codes billable every month.
Recognition can also earn credit under Medicare quality programs. Revelrex helps practices reach and keep recognition; ask us which payers in your state pay for it.
Which payers in your state pay for PCMH?
A 30-minute call with a Revelrex PCMH specialist: we check your payer mix, the programs available to you and what recognition would take. No obligation.