Compliantly earn revenue while amplifying chronic care with GAIN: Guided Agent-Enabled Individualized Nursing

Since our GAIN launch, we’ve covered our launch vision and how the care platform works. In this post, we’ll cover i) compliance with reimbursements, like APCM (Advanced Primary Care Management), and ii) financial impact. This is important because achieving our mission of transforming care requires our platform be financially sustainable, and accessible to all needy patients.

Compliance

To ensure GAIN’s enterprise-level compliance, we partnered with compliance expertise with deep experience. This includes ~30 years' total spread across i) senior roles in Government Affairs at large healthcare firms, specializing in CMS coding/payment, and ii) service with federal advisory committees and groups on digital health.

APCM: Unlocking Nurse Amplification

While CCM has been around for a decade, APCM only launched in January of 2025 and is Medicare’s newest monthly care management benefit. It bundles CCM and TCM into a simplified model (while RPM/RTM can still be billed separately) and removes old “time minimum” requirements. This is transformative because APCM allows providers to be compensated for efficient care vs. simple human minutes (regardless of efficiency) per prior models like CCM.For CircleLink's GAIN platform, APCM means we can provide evidence-based and clinically effective agentic outreach for patients who may not need a full RN call. NOTE: GAIN ensures an RN (or provider care team) is always in the loop communicating directly with the chronic care patient, and responsive to any escalations needed. This lets us drive outcomes at a lower cost/reimbursement to Medicare vs. CCM, while still driving provider profits & new revenues.Re: APCM's details, patients qualify with one or more chronic conditions, with most payments ranging form ~$50–$120 per patient per month (codes G0557–G0558, depending on complexity). Compliance centers on clinically appropriate monthly touchpoints—nurse calls, condition surveys, psychosocial screenings, and closing preventive gaps—helping reduce readmissions and improve outcomes. Here’s a summary of APCM requirements:CategoryRequirement(NOTE: Below items only required when clinically appropriate, not every month)Consent & Initiation

• Written or verbal patient consent
• initiating visit (paid separately) unless: Patient seen in past 3 years by you/your practice, OR Patient received APCM/CCM/PCM in the past year, OR Provider responsible for APCM performed the Medicare Annual Wellness Visit (AWV).

Access & Continuity

• Provide 24/7 access and ensure continuity of care
• Allow patients to schedule successive routine appointments with the same care team member
• Offer alternative care delivery (e.g., home visits, expanded hours)

Comprehensive Care Management

• Medical + psychosocial assessments
• System-based approaches to ensure preventive services
• Provide meds reconciliation and management, support for self-management
• Develop, implement, revise, and maintain an electronic patient-centered care plan
• Coordinate care transitions across providers and settings

Enhanced Communication

• Offer non-face-to-face options beyond phone (secure messaging, email, patient portal)
• Support remote evaluation of pre-recorded patient info and interprofessional consults via phone, internet, or EHR
• Enable patient-initiated digital communications requiring clinical decision-making (e.g., virtual check-ins, e-visits).

Population Health Analysis

• ID gaps in care
• Risk stratify the practice population and target services to patients

Value-based care participation

• 1 of below must be done:
  • i) Report the Value in Primary Care MIPS Value Pathway (MVP). OR
  • ii) be in MSSP ACO, REACH ACO, Making Care Primary model, or Primary Care First model

Source: CMS APMC summaryImportantly, all of the above need not be accomplished each month to bill APCM. Instead, only the month of service’s clinically appropriate/needed items must be fulfilled to achieve APCM reimbursement.

GAIN Financials

On the financial side, GAIN’s incentives typically include reimbursements for Advanced Primary Care Management (“APCM”) and Chronic Care Management (“CCM”), among other incentives. APCM typically pays ~$55 per patient per month while CCM typically pays ~$65-100 per patient per month. So per 1000 enrolled patients, providers can earn ~$800K of additional annual revenue, with ~50% net margins. (Assumes 1 month CCM + 7 months APCM per average patient.) Interested in learning more? Join our October 23rd webinar for an in-depth discussion.

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