Outreach and enrollment support
We contact eligible Medicare patients, explain the program, and support consent and onboarding workflows.
CCM Program for Clinics
Medicare Chronic Care Management support for Pennsylvania clinics.
Scarlet Lau, PharmD, MPH helps clinics run a compliant, patient-centered CCM program without adding staff.
What We Do
We handle the time-intensive CCM workflow.
PivotWell Health supports the recurring operational work clinics need to keep CCM consistent, documented, and patient focused.
Monthly care calls
We complete structured monthly check-ins focused on chronic conditions, care gaps, patient concerns, and next steps.
Medication review
PharmD-led review helps identify adherence issues, medication questions, duplications, and follow-up needs.
Care coordination
We help connect patient needs back to the clinic team, community resources, specialists, and care plans.
Documentation
We prepare organized monthly notes that support continuity, supervision, and billing review.
Billing summaries
We provide claim-ready summaries so the clinic can review, approve, and bill Medicare under its program.
What Your Clinic Does
Your team keeps control of the program.
The clinic remains the Medicare billing provider and supervising clinical entity while PivotWell Health supports the CCM workflow.
- Refer eligible Medicare patients with two or more chronic conditions.
- Supervise the CCM program and review relevant patient updates.
- Bill Medicare for eligible CCM services when requirements are met.
- Keep program revenue without hiring additional in-house staff.
Revenue Potential
A recurring service line for patients you already serve.
CCM can create a monthly Medicare billing opportunity for eligible patients when consent, time, documentation, supervision, and billing requirements are satisfied.
Designed for clinics that need capacity, not more payroll.
PivotWell Health helps clinics activate CCM by taking on outreach, calls, coordination, and documentation support. Your clinic bills Medicare and retains the revenue from its supervised program.
Why PharmD-led CCM
Medication expertise belongs inside chronic care management.
Many CCM patients manage multiple conditions, specialists, medications, and barriers to adherence. A pharmacist-led approach brings practical medication insight to every monthly touchpoint.
Medication risk awareness
Pharmacist review helps surface adherence problems, side effects, duplicate therapy, and patient confusion.
Patient-centered calls
Monthly conversations can uncover care gaps, access issues, and questions patients may not raise during brief office visits.
Cleaner clinic workflow
Structured documentation and summaries help the clinic supervise the program without building a new internal team.
How It Works
A simple operating model.
Identify
Your clinic identifies eligible Medicare patients who may benefit from CCM.
Enroll
PivotWell Health supports outreach, program explanation, and enrollment workflow.
Support
We complete monthly calls, medication review, coordination, and documentation.
Bill
Your clinic reviews the monthly summary, bills Medicare, and keeps the revenue.
About Scarlet
Scarlet Lau, PharmD, MPH
Scarlet helps Pennsylvania clinics turn Medicare Chronic Care Management into a practical, supervised service line. Her pharmacy and public health background supports patient outreach, medication review, care coordination, documentation, and clear operational follow-through.
CTA
Discuss CCM support for your clinic.
Connect with PivotWell Health to review your clinic's patient population, workflow, and CCM support needs.