Vigil Health handles the structured work of Chronic Care Management and Advanced Primary Care Management — automated patient check-ins, documented care plans, real-time alerts, hospitalization tracking, and audit-ready billing — so your care team can focus on what actually matters.
Chronic patients get consistent support between appointments. Your practice stays on top of their care — and the documentation handles itself.
Every enrolled patient gets a documented care plan — chronic conditions, measurable goals, and a medication list. Not a formality. A living record your team actually uses.
Automated check-in calls reach patients on a schedule that fits their needs. Ten structured health questions surface pain, medication problems, and emotional distress. The call time itself doesn't count toward the 20-minute threshold — your coordinator's follow-up work does.
Urgent responses trigger real-time alerts to your care team. Everything is documented automatically, so your providers can focus on patients — not paperwork.
How CCM time actually works
Automated check-in calls are structural outreach — not billable. Vigil excludes them at the data layer.
Reviewing alerts, following up on calls, updating care plans — this is the 20 minutes that matters.
Care plan edits, medication management, coordination with providers — all logged with timestamps.
CMS requires 20+ minutes of qualified clinical staff time per patient, per month — not automated system time. Vigil is built around this distinction from the ground up.
The tools your care team needs to run both programs compliantly — chronic care management, advanced primary care, hospitalization tracking, and population reporting in one platform.
AI-powered voice calls check in on enrolled patients on your schedule — daily, weekly, bi-weekly, or monthly. AMD voicemail detection included.
AES-256-GCM encryption for all PHI, mandatory two-factor authentication, AAL2 session enforcement, and an append-only audit trail.
Session timers, manual logs, and precise start/end timestamps for every care activity. AI call time and telephony time are structurally excluded — only your team's work counts.
Full CPT 99490 / 99439 CCM workflow and APCM G-code billing (G0556, G0557, G0558). The system suggests the optimal program per patient each month so practices never leave reimbursement on the table.
Advanced Primary Care Management requires no time threshold — it bills on care management activities. Vigil tracks coordinator actions, surfaces the right G-code, and locks in a care plan snapshot at attestation.
Log hospital admissions, ER visits, and SNF stays. Automatic follow-up task creation, due-date tracking, and resolution logging — built directly into the APCM attestation evidence trail.
A Claude-powered assistant answers CCM and APCM protocol questions, care plan guidance, and billing code questions — without processing patient PHI.
AI classifies check-in responses by severity. Urgent alerts trigger coordinator SMS in real time. All alerts are tracked to resolution.
Problem lists, measurable goals, interventions, and medication management — structured for documentation audits and CMS reviews. APCM attestations snapshot the active care plan.
Export APCM population metrics — contact rates, hospitalization rates, documentation quality — formatted for MIPS quality reporting. Year-over-year comparison built in.
Printable monthly CCM billing summaries, APCM audit bundle exports, and outreach history — everything your billing department and compliance officer need.
Separate login tiers for care coordinators, supervising providers, and practice admins — each scoped to only the data they need.
Patients managing diabetes, heart failure, COPD, or hypertension face daily challenges that their care team rarely gets to hear about. Medication side effects, worsening symptoms, and social stressors build up quietly in the weeks between visits.
Vigil calls them. Not a reminder, not a portal message — a real voice call that asks how they're doing, listens for warning signs, and connects them back to their care team the moment something sounds wrong.
Patients know someone is paying attention. That alone changes outcomes.
Regular scheduled calls mean no patient goes weeks without contact. For isolated or elderly patients, this connection is meaningful in itself.
When a patient reports severe pain, trouble breathing, or can't afford their medication, the care team is alerted in real time — not at the next appointment.
Goals, medications, and interventions are documented and updated by the care team — not filed and forgotten. Patients have a team that knows their history.
Every call, every response, every note is encrypted and secured to HIPAA standards. Patients' information is never shared, sold, or logged carelessly.
False Claims Act exposure, HIPAA enforcement, and Anti-Kickback risks are real. Vigil Health enforces the compliance requirements that other platforms leave to you — structurally, at the database level.
We don't hide what these programs take to run well. Good care management is valuable because it requires a real human to do the work — not because it happens automatically.
Vigil does the automated outreach. Your coordinator reviews alerts, follows up on flagged responses, updates care plans, and logs their time. Most panels of 50–100 patients take 8–12 hours per month.
Every patient needs to opt in, have their consent documented, and confirm they're not enrolled elsewhere. Vigil tracks this — but your team needs to have the conversation.
A supervising provider must review and attest to the care provided each month. Vigil builds the attestation flow — takes about 2 minutes per patient.
Patients must have had a qualifying visit with your practice before CCM billing begins. Vigil gates enrollment — you ensure the visit is on file.
Every role gets a scoped view of the platform — only the data and actions relevant to their job. Select a role to see their features, workflow, and what they need to know.
The coordinator is the engine of the program. They handle daily patient contact, document every coordination activity, log hospitalization events, and prepare billing periods for provider review.
What they can do
Step-by-step workflow
Morning alert review
Open the Alerts tab. Vigil flags any check-in responses that mention severe pain, breathing difficulty, medication issues, or emotional distress. Work through the queue — resolve each alert, log your callback time, and document the outcome.
Log coordination time
Go to Time Log. Use the session timer for live work or manual entry for retrospective logging. Select the activity type (care coordination, care plan review, provider communication, etc.). Start and end timestamps are captured automatically.
Document APCM actions
For each APCM-enrolled patient, open their APCM Checklist. Log coordinator actions — care transitions follow-up, patient education, medication reconciliation, specialist communication, and more. Three documented actions are required before attestation.
Log hospitalizations
If a patient reports a hospital stay during a call or follow-up, open the patient record and log the admission. Record the admission date, facility, admission type, and whether follow-up is required. Vigil creates a follow-up task and tracks completion.
End-of-month billing prep
Go to Billing → Progress. Review each patient's CCM minutes or APCM action count. For patients who didn't hit the 20-minute CCM threshold, check whether APCM applies. Once ready, mark the billing period for provider attestation.
Key rule
Every minute you log and every action you document is the evidence base for billing. Vigil floors your totals once — it never rounds up — so every second you work compounds toward the threshold accurately.
One-time onboarding. Monthly per enrolled patient. No annual contracts.
We're enrolling our first cohort of practices. As a founding practice you get our full attention during onboarding, direct access to the product team, and a permanent discount on the setup fee — in exchange for honest feedback as we grow the platform together.
Standard setup fee
$1,000
Your setup fee
$500
50% founding discount
Monthly per patient
$25
enrolled patients only
Setup fee billed via ACH after we review and activate your account. Monthly billing begins with your first enrolled patient.
Everything included, no tiers:
You pay only for enrolled patients. Monthly invoices via ACH — no cards, no auto-charge.
Pricing starts at $25/patient and scales down for larger panels. Talk to us about your panel size.
CCM and APCM are two of the few Medicare programs that directly pay for keeping patients out of the hospital. Here's a realistic combined example — 40 CCM patients hitting the 20-minute threshold plus 40 APCM patients across all three G-code tiers. Use the calculator to model your panel.
| Item | Monthly (est.) |
|---|---|
| CCM 99490 × 40 patients (~$62 ea.) | $2,480 |
| CCM 99439 add-on × 12 patients (~$48 ea.) | $576 |
| APCM G0558 × 15 QMB patients (~$117 ea.) | $1,755 |
| APCM G0557 × 18 patients (~$50 ea.) | $900 |
| APCM G0556 × 7 patients (~$15 ea.) | $105 |
| Total Medicare billed (80 patients) | ~$5,816 |
| Vigil platform (80 × $25) | −$2,000 |
| Net before coordinator time | ~$3,816 |
2024 national averages. Medicare GPCI adjustments, payer mix, and collection rates affect actual revenue. Coordinator time is not included — typical practices allocate 8–12 hours/month per 100 patients.
CCM — CPT 99490 + 99439 (20-min threshold)
APCM — no time threshold required
2024 national Medicare estimates: 99490 ~$62, 99439 ~$48, G0558 ~$117, G0557 ~$50, G0556 ~$15. Actual rates vary by locality (GPCI), payer mix, and collection rate. Coordinator time is not included — typical practices allocate 8–12 hours/month per 100 patients.
CMS sets the eligibility requirements. Vigil enforces them at enrollment and suggests the higher-reimbursing program for each patient each month.
Patient must have had a face-to-face visit with your practice within the past 12 months.
Diagnosed and documented. Expected to last at least 12 months or until death.
Part B must be primary. Medicare Advantage plans vary — verify coverage before enrolling.
Verbal or written. Must include single-biller confirmation. Vigil tracks consent status and blocks billing if revoked.
Same as CCM — Medicare Part B must be primary. Medicare Advantage plans vary.
APCM requires only 1+ chronic condition (vs. CCM's 2+). G-code tier is determined by condition count and QMB status.
Qualified Medicare Beneficiaries (low-income subsidy) qualify for G0558 — the highest-reimbursing APCM code at ~$117/month.
Unlike CCM, APCM has no 20-minute threshold. Billing is based on documented care management activities — coordinator actions, care plans, hospitalizations.
A patient can be enrolled in CCM or APCM — not both simultaneously. Vigil tracks program selection per billing month and prevents duplicate billing.
People living with two or more chronic conditions spend most of their lives outside the doctor's office. They manage medications, symptoms, and setbacks largely on their own — and too often, small problems become serious ones before anyone on their care team finds out.
Medicare's Chronic Care Management program was designed to change that. It funds the between-visit care that independent practices already want to provide — regular check-ins, documented care plans, and a care team that stays connected. But the administrative burden of running a real CCM program has kept most small practices from doing it well.
Vigil removes that burden. We built the infrastructure — secure, compliant, and purpose-built for independent practices — so care coordinators can focus on patients instead of paperwork.
Better outcomes for patients. Less administrative overhead for practices. That's the whole idea.
Chronically ill patients spend most of their lives outside the doctor's office. Vigil calls them monthly, catches problems early, and makes sure no one falls through the cracks between visits.
Independent practices want to provide great between-visit care — they just can't afford the administrative burden of running it manually. Vigil handles the calls, documentation, and billing so physicians can focus on medicine.
Preventable ER visits and hospital admissions cost Medicare billions each year. Consistent monthly check-ins catch deteriorating conditions before they escalate — keeping patients healthier and out of the emergency room.
The Founding Practice Program is open now. Submit your practice and we'll reach out within 24 hours to get you started. No sales call required.
Evaluating CCM platforms? Want to see a walkthrough? Have compliance questions? We respond to every message within one business day.
Security disclosure
To report a vulnerability, email us with "SECURITY" in the subject. We follow responsible disclosure and respond within 48 hours to verified reports.