Service Before Software
We operate care programs. We do not sell access to a platform and leave your team responsible for delivery.
About MatterCCM
Built for the realitiesbehind the program.
MatterCCM was built around a straightforward belief: patients with chronic and complex needs deserve a healthcare experience that does not disappear between appointments.
Healthcare organizations want to provide that continuity. Many simply lack the staffing, workflows, technology, controls, and operating capacity to deliver it consistently at scale.
We exist to close that gap.
Our Purpose
To make continuous care practical for every healthcare organization.
Independent practices should be able to offer meaningful care management without constructing an entirely new department.
Large healthcare organizations should be able to expand longitudinal care without sacrificing local workflows, clinical relevance, or leadership visibility.
Patients should receive support that feels connected to their provider—not outsourced to an anonymous queue.
MatterCCM brings the people, operational structure, technology, and accountability required to make those things possible.
A Complete Operating Partner
We do not give you another program to manage. We manage the program with you.
MatterCCM can support the complete care management lifecycle:
Your providers retain clinical authority. Your organization retains visibility. Our teams provide the operating capacity required to make the program work consistently.
- Patient-population assessment
- Eligibility identification
- Program and workflow design
- Patient outreach and education
- Consent and enrollment support
- Comprehensive care-plan development
- Recurring patient engagement
- Medication and care coordination
- Transition and referral support
- Clinical escalation
- Documentation and quality review
- Billing-ready service reporting
- Program analytics
- Ongoing performance governance
What the Research Shows
Primary care was never meant to carry this alone.
26.7 hours
a day: the estimated time one primary care physician would need to deliver guideline-recommended care to a 2,500-patient panel alone, against 9.3 hours with team-based care.1
View source (opens in a new tab)50%
average adherence to long-term therapy for chronic illness in developed countries, according to the World Health Organization (2003).2
View source (opens in a new tab)$74
slower growth in Medicare spending per patient per month for CCM recipients than for a matched comparison group over 18 months, net of the CCM fee.3
View source (opens in a new tab)
Sources
- Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. Journal of General Internal Medicine 2023;38(1):147–155. doi.org/10.1007/s11606-022-07707-x↩
- World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. Geneva: WHO; 2003. iris.who.int↩
- Schurrer J, O’Malley A, Wilson C, McCall N, Jain N. Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services: Final Report. Mathematica Policy Research for the Centers for Medicare & Medicaid Services; November 2017. cms.gov↩
Published industry research, not MatterCCM program results. Outcomes for any organization depend on its population, implementation and program design.
Why Organizations Choose MatterCCM
Clinical Work and Operational Control
Care delivery, documentation, workflow, quality, escalation, and reporting are managed as connected responsibilities.
Flexible by Organization
The model can support a single practice, multiple specialties, dispersed locations, facility-based care, or enterprise-scale populations.
Meaningful Patient Engagement
Interactions are designed around the patient’s care plan and current needs—not a generic monthly script.
Provider-Aligned Delivery
Protocols, escalation expectations, communication, and clinical authority remain aligned with the participating provider organization.
Visible Performance
Leaders receive a clearer view of enrollment, engagement, completion, exceptions, and program operations.
Sustainable Growth
Programs can expand without requiring the client to recreate staffing, training, workflow, and oversight infrastructure each time.
What a Stronger Program Can Create
More continuity for patients. More control for healthcare organizations.
A well-operated care management program can support:
- More consistent patient engagement
- Better-organized care coordination
- Earlier recognition of emerging needs
- Greater support between encounters
- Clearer medication and care-plan follow-through
- Stronger transition workflows
- Less administrative burden on existing staff
- More consistent documentation
- Better billing readiness
- Clearer leadership visibility
- A scalable foundation for value-based care
- A more sustainable patient-care model
Actual results vary by organization, population, implementation, provider involvement, payer mix, and program design.
Human Care, Delivered Consistently
Patients should feel supported—not processed.
Effective care management requires more than completing a monthly contact.
Patients need to understand who is calling, why the program matters, how it relates to their provider, and what support is available to them. They need conversations that reflect their conditions, goals, barriers, medications, recent experiences, and changing circumstances.
Our patient-engagement model is built around- Clear program education
- Respectful consent conversations
- Familiar and consistent communication
- Individualized care goals
- Active listening
- Medication understanding
- Appointment and referral coordination
- Identification of practical barriers
- Appropriate escalation
- Communication that reflects the provider’s standards
Our Team Structure
MatterCCM does not depend on one visible personality.
Clients are supported through an organized delivery structure that may include:
- Implementation leadership
- Clinical program oversight
- Care-management personnel
- Patient-engagement teams
- Workflow and EHR specialists
- Quality assurance
- Documentation review
- Billing-readiness support
- Data and performance analysis
- Client success and program governance
The result is institutional capability rather than dependence on a single individual.
The Continuity Standard™
A program is only as strong as the system behind every patient interaction.
The Continuity Standard brings clinical delivery, operating controls, quality assurance, documentation, and performance management into one disciplined framework.
Assess
We evaluate your patient population, care environment, current workflows, EHR structure, staffing model, payer considerations, and strategic goals.
Design
We configure the program around your organization rather than forcing your organization into a standard template.
Activate
We identify eligible populations, prepare workflows, align teams, support patient outreach, and establish clinical and operational escalation pathways.
Deliver
Our care teams perform recurring care-management activities under defined protocols and provider direction.
Validate
Documentation, activity, enrollment, exceptions, and billing readiness are reviewed through structured controls.
Improve
Program performance is reviewed with your organization so enrollment, engagement, workflow, patient experience, and operational outcomes can improve over time.
Technology Behind the Service
Your team should experience the benefit of technology—not the burden of operating it.
ContinuityOS supports the work behind every program. It helps our teams organize patient populations, manage workflows, maintain care-plan activity, document interactions, track exceptions, support quality review, prepare service reporting, and provide leaders with actionable visibility.
Technology brings structure and scale. People bring judgment, communication, empathy, and accountability. MatterCCM brings both together.
Technology Capabilities
The Platform
Eight programs. One login.
Most organizations end up running each reimbursable program on a different tool, then reconciling them by hand at month end. All eight live in one environment here — one dashboard, one billing engine, one patient record.
- RPMRemote Patient Monitoring
- CCMChronic Care Management
- RTMRemote Therapeutic Monitoring
- TCMTransitional Care Management
- PCMPrincipal Care Management
- BHIBehavioral Health Integration
- MTMMedication Therapy Mgmt
- PINPrincipal Illness Navigation
Clinical Workflow & Patient Management
- One dashboard carrying device data, care-plan status and open alerts across every program
- At-risk identification for out-of-range readings and missed monitoring days
- Clinical pathways and alert thresholds configurable by condition and program
- Automated SMS, phone and email outreach, including adherence reminders
- One patient can sit in RPM, CCM and BHI at once without a duplicate record
Device Management & Data Ingestion
- 40+ connected devices: blood pressure, glucose, weight, SpO₂, spirometry, temperature, adherence
- Native support for Roche, Abbott, Dexcom, A&D, Apple and others
- Cellular devices ship direct to the patient — most readings need no Wi-Fi and no app
- Readings arrive as they are taken, at whatever frequency and thresholds that patient is set to
- Ordering, shipping, stock and patient assignment all handled here rather than on a vendor portal
Billing & Revenue Cycle
- CPT documentation assembled automatically for every program
- Time tracked against billing thresholds as it accrues, including the 20-minute RPM minimum
- A monthly summary your billing team can submit without rebuilding it first
- Consent and enrollment held on file and exportable whenever an audit asks for them
Reporting & Analytics
- Where the population stands: who is enrolled, who is compliant, what alerted, what was reimbursed
- A single patient's readings plotted over 30, 60 and 90 days
- The same measures compared across providers, sites and individual care managers
- Exports built for the EHR, or a direct push into it where the integration exists
Security & Compliance
Built for healthcare data.
We hold PHI for more than 100,000 patients across 45+ states, audited independently against the standards your organization has to answer for.
HIPAA Compliant
Compliance carried across the platform, storage, transmission and every device integration. A BAA is executed with each client at onboarding.
SOC 2 Type II Certified
Audited annually by independent third parties against security, availability, processing integrity, confidentiality and privacy.
End-to-End Encryption
Encrypted in transit on TLS 1.2+ and at rest under AES-256. Device transmissions run over encrypted cellular or Wi-Fi.
Role-Based Access & MFA
Access restricted to authorized users by role, MFA on every account, and an audit log behind each data-access event.
U.S. Data Residency
Patient data held in U.S.-based, HIPAA-eligible cloud infrastructure, and never outside the United States.
Audit-Ready Documentation
Consent, device data, time logs and clinical notes retained and exportable for any payer or OIG audit.
Build It Or Partner
The same program, run two different ways.
| Consideration | In-House CCM | Managed by MatterCCM |
|---|---|---|
| Staffing cost | NoHire, train and retain dedicated care-management staff | YesNo additional headcount; our care teams operate the program |
| Setup time | NoMonths of workflow design, hiring and system build | YesStructured launch on a defined implementation schedule |
| Audit risk | NoDocumentation and time-tracking accuracy sit with your team | YesDocumentation controls and billing-readiness review included |
| Monthly revenue | NoProgram revenue offset by internal operating cost | YesProgram revenue retained without building a department |
In Their Words
We were leaving chronic care management on the table because we could not staff it. Within two quarters it became a dependable monthly line rather than a project we kept postponing, and none of that came out of clinic time.
Practice AdministratorIndependent Primary Care Group The difference shows up between appointments. Someone is checking in on our most complex patients every month, and problems reach us while they are still small enough to handle over the phone.
Medical DirectorMultispecialty Group I expected another implementation to manage. Our team handed over the patient list, sat in on the workflow sessions, and the documentation started arriving in the chart the way we already work.
Director of Clinical OperationsRural Health Clinic
Your eligible population already exists.
The next step is determining how to serve it responsibly, consistently, and at the right scale.
MatterCCM will assess your population, current capabilities, care environment, and program goals—and recommend an operating model built around your organization.
Common Questions
Is MatterCCM a software company?
No. MatterCCM is a care management services company. We use internal technology to coordinate delivery, strengthen controls, support integrations, and provide visibility, but our principal offering is the operation of care-management programs.
Do we need to replace our EHR?
No. Our model is designed to work around the systems and workflows already used by the participating organization. Integration and workflow requirements are evaluated during program design.
Can MatterCCM support a small practice?
Yes. The operating model can be configured for independent and smaller practices that do not have the staffing or infrastructure to build a care-management department internally.
Can you support multiple locations or specialties?
Yes. Programs can be designed around multiple locations, provider groups, specialties, EHR workflows, facilities, and patient populations.
Does MatterCCM handle billing?
Our services can include billing-readiness controls, documentation validation, service reporting, and coordination with the client’s billing operation. The exact division of responsibility is defined during implementation.
Can we keep part of the program in-house?
Yes. MatterCCM can operate an entire program or support selected components such as eligibility, enrollment, care planning, patient engagement, quality review, or performance management.
How quickly can a program launch?
Launch timing depends on population size, EHR access, workflow complexity, clinical protocols, staffing decisions, integrations, and the services selected. A preliminary implementation range is provided following the program assessment.
Does this create extra work for our staff?
No. Our care teams do the work. Your providers retain clinical authority and your organization retains visibility.
Does this replace visits with our physicians?
No. It is care between normal visits. Patients stay with their own providers.
How do we bill for it?
We send monthly logs your team submits as CPT claims. Practices that would rather not handle billing internally can be referred to BillerBay.