Advanced Primary Care Management (APCM): A New Opportunity to Improve Outcomes and Strengthen Primary CareHuman-Led. AI-Enabled. Better Care Between Visits.

Healthcare continues to shift toward proactive, patient-centered care. Yet many patients with chronic conditions still struggle between office visits—missing medications, delaying follow-up appointments, and facing barriers that can ultimately lead to worsening health outcomes and avoidable utilization.

To address this challenge, Medicare recently introduced Advanced Primary Care Management (APCM), a new reimbursement pathway designed to support ongoing, comprehensive care coordination for patients while strengthening the role of primary care.

At MayaMD, we believe APCM represents one of the most important new opportunities for practices to improve patient outcomes, enhance patient engagement, and generate sustainable reimbursement—all without adding significant burden to clinical staff.

What is Advanced Primary Care Management (APCM)?

Advanced Primary Care Management (APCM) is a Medicare care management program that supports comprehensive, longitudinal care for patients with chronic conditions.

Unlike traditional Chronic Care Management (CCM), APCM does not require monthly time tracking. Instead, it focuses on ensuring practices have the infrastructure and capability to provide coordinated, patient-centered care across the continuum.

APCM is reimbursed monthly through Medicare using three HCPCS codes based on patient complexity:

• G0556 – Patients with 0–1 chronic condition
• G0557 – Patients with 2 or more chronic conditions
• G0558 – Qualified Medicare Beneficiaries (QMB) with 2 or more chronic conditions

The goal is simple: help patients receive the support they need between visits while enabling providers to deliver more proactive, coordinated care.

Why APCM Matters

For many healthcare organizations, the challenge isn't identifying patients who need support—it's having the resources and workflows necessary to provide it consistently.

Patients often need assistance with:

• Medication adherence
• Follow-up appointments
• Care transitions
• Preventive care
• Education about chronic conditions
• Navigating multiple providers and specialists
• Addressing social and behavioral barriers to care

Without ongoing engagement, patients frequently fall through the cracks.

APCM creates a framework that allows practices to provide this support while being appropriately reimbursed for the work involved.

The MayaMD Difference: More Than Software

Many APCM vendors focus primarily on workflow tools and documentation platforms.

MayaMD takes a different approach.

We combine technology, dedicated care team support, and AI-powered patient engagement into a complete solution that functions as an extension of your practice.

Dedicated Medical Assistants

Our trained medical assistants support:

• Patient enrollment and consent
• Comprehensive patient assessments
• Care plan development
• Ongoing patient outreach
• Education and engagement
• Care coordination activities
• Follow-up support

Rather than adding work to your staff, MayaMD helps reduce administrative burden while improving patient touchpoints.

AI-Powered Patient Engagement

MayaMD's proprietary hybrid AI platform delivers personalized patient engagement at scale.

Patients receive:

• Personalized education
• Appointment reminders
• Medication reminders
• Symptom assessments
• Condition-specific guidance
• Health coaching and support

This enables practices to maintain meaningful engagement between visits while improving patient adherence and satisfaction.

Personalized Care Plans

Every patient receives a care plan tailored to their:

• Chronic conditions
• Medications
• Health risks
• Personal goals
• Barriers to care

These individualized plans help improve patient understanding while creating a roadmap for ongoing care.

Care Coordination Support

MayaMD helps facilitate communication and coordination among:

• Primary care providers
• Specialists
• Caregivers
• Community resources
• Other members of the healthcare team

This coordinated approach helps improve continuity of care and patient outcomes.

Benefits for Patients

Patients enrolled in APCM receive support that extends beyond the traditional office visit.

Benefits may include:

Better Access to Care

Patients have ongoing access to support and guidance between appointments.

Earlier Intervention

Regular outreach helps identify concerns before they become emergencies.

Improved Care Coordination

Patients receive help navigating referrals, specialists, medications, and follow-up care.

Enhanced Patient Experience

A dedicated care team helps patients stay informed, supported, and connected to their healthcare providers.

Personalized Support

Care plans and outreach are tailored to each patient's unique needs and health goals.

Benefits for Providers and Health Systems

APCM creates meaningful value for healthcare organizations.

Generate New Reimbursement Opportunities

Capture monthly APCM reimbursement while delivering high-quality patient-centered care.

Improve Patient Engagement

More frequent touchpoints help strengthen relationships and improve adherence.

Support Value-Based Care

APCM aligns with population health, quality improvement, and value-based care initiatives.

Reduce Administrative Burden

MayaMD manages many of the operational components required to support APCM programs.

Scale Without Hiring Additional Staff

Our remote care infrastructure functions as an extension of your existing practice.

How MayaMD Supports APCM

Our APCM workflow is designed to be simple and scalable:

1. Patient identification and enrollment
2. Consent collection
3. Comprehensive patient assessment
4. Personalized care plan creation
5. Ongoing patient engagement
6. Care coordination and follow-up
7. Documentation support
8. Monthly review and optimization

The result is a streamlined process that helps practices launch and scale APCM efficiently.

The Future of Primary Care Is Proactive

Healthcare is increasingly moving beyond episodic office visits toward continuous patient engagement, proactive care management, and coordinated care delivery.

APCM represents an important step in that evolution.

Practices that successfully implement APCM can strengthen patient relationships, improve outcomes, support value-based care initiatives, and create sustainable reimbursement opportunities.

At MayaMD, we're helping providers do exactly that through a combination of dedicated care teams, personalized care planning, AI-powered patient engagement, and scalable remote care infrastructure.

Ready to Launch APCM?

MayaMD makes it easy to implement Advanced Primary Care Management without adding burden to your clinical staff.

Schedule a demonstration to learn how MayaMD can help your organization improve patient outcomes, strengthen care continuity, and successfully scale APCM services.

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