Care management for athenahealth practices · on the Marketplace

The cognitive work of care, finally counted — on athena.

Willowbridge captures every minute your team spends keeping Medicare patients out of the ER — every chart review, phone call, medication reconciliation, family conversation — signs the clinical attestation, and hands the structured charge to athenahealth. athena bills, athena collects, your team focuses on the patient. No new biller, no new clearinghouse, no PDF-shuffle between systems.

Built for
Primary care Cardiology Nephrology Endocrinology FQHCs
demo.willowbridge.app/patients/edith-marsh
14:32
Encounter in progress · Edith Marsh
Phone · CCM · started 10:18a

Today's patients

12 on your panel · Sat · May 17
EM
Edith Marsh · 78 Call due
HTN · HF · DM-II — overdue by 1 day
14 / 20 min
RT
Roy Tanaka · 71 Review due
Care plan annual review by May 22
8 / 20 min
BL
Beatrice Liu · 69 RPM setup
BP cuff paired — needs 16 days of readings
3 / 16 days
JF
Jorge Fuentes · 74 Ready to bill
Signed by Dr. Velasquez · 22 min documented
22 / 20 min
The gap between care given and care billed

You're already doing the work. You're just not getting paid for it.

CMS pays for this care — and the published evidence says it works. The hard part isn't deciding to do it. It's capturing the cognitive minutes, across a staff team, in a record that survives an audit. Most practices leave the revenue, and the outcomes, on the table.

$66/ patient / mo
National Medicare payment for CCM (CPT 99490, 20 min of clinical staff time) — ~$66.30 in CY 2026, the national average per eligible patient per month. That money mostly goes uncaptured because the 20 cumulative minutes are spread across staff and never substantiated.
SOURCE · CMS MEDICARE PHYSICIAN FEE SCHEDULE, CY 2026
−$74/ bene / mo
Lower acute-care Medicare spending for beneficiaries receiving CCM, over an 18-month evaluation — alongside higher rates of advance care planning and improved patient-reported satisfaction and adherence.
SOURCE · MATHEMATICA, CCM EVALUATION FOR CMS, 2017
1.0%vs 1.6%
Mortality in the 31–60 days after discharge for beneficiaries who received transitional care management vs those who didn't — with adjusted total Medicare costs of $3,033 vs $3,358. Across 18.7M discharges.
SOURCE · BINDMAN & COX, JAMA INTERNAL MEDICINE, 2018
Capture · Document · Defend

One workflow. Every billable minute.

The hardest part of CCM isn't the care — it's tracking the care in a way that's still defendable in November when an auditor asks about a claim from March. Willowbridge runs the whole loop: one encounter timer captures the time, drafts the note from the chart, and queues the claim with its audit packet pre-assembled. Your team works the panel; the billing happens around them.

1

A timer attached to the work, not a Post-it.

One tap starts an encounter from a worklist row, the chart, a phone widget, or the EHR sidebar. The mm:ss counter rides at the top of the screen the whole time the encounter is open, with the month-to-date total broken out by program (CCM, PCM, BHI, RPM, TCM) so you always know whether you're under, at, or over a billable tier. The clock pauses when you switch context, resumes when you return, and rolls up cumulative time across the whole care team for the calendar month.

2

Topic chips that pre-structure the note.

Tap "medication adherence," "symptom check," "care plan review," "SDOH" — and Willowbridge drafts a clinical narrative from the chart under each section header. You write prose into structure, not into a blank page. The note links automatically to the encounter and the rendering provider, with the right CPT code already attached.

3

Sign as you go. Review the month in one pass.

The rendering provider signs each encounter as it happens, not in a stack at month-end. There's still one monthly billing-period sign-off per program — but by the time it hits the review queue, the audit packet is already assembled, so it's a single review pass, not a reconstruction across 200 charts.

4

An audit packet on every claim.

Every submitted claim ships with a contemporaneous evidence file: consent on the date of service, care plan version pinned to that date, the time log with timestamps and signers, threshold-met indicator, modality, and place of service. When your MAC asks about a claim from March in November, you have the answer in seconds, not days.

Call outcome

Audio · 14:23 logged · attached to encounter #EC-4421
OUTCOME
✓ Spoke with patient · counted Spoke with caregiver Left voicemail No answer Patient unavailable Wrong number Abandoned
PARTICIPANTS
✓ Patient + Caregiver + Family member + Other clinician + Interpreter
TOPICS DISCUSSED
✓ Medication adherence ✓ Symptom check + New labs ✓ Care plan review + Education + Care coordination + SDOH
CLINICAL NOTE auto-templated · edit freely
Programs covered

Every care management program Medicare pays for.

From CCM and RPM to the more nuanced revenue lines like Principal Care Management, Behavioral Health Integration, and Transitional Care Management — Willowbridge models the time thresholds, eligibility rules, and modifier interactions for each one. Add a program, and the worklist updates the same day.

CHRONIC CARE
CCM
Two or more chronic conditions expected to last ≥ 12 months. 20-min cumulative non-face-to-face time per calendar month.
994909943999487994899949199437
REMOTE PHYS. MONITORING
RPM
Device setup, 16+ days of readings in 30, plus 20 minutes of treatment management. Willowbridge handles device pairing and reading thresholds.
99453994549945799458
PRINCIPAL CARE
PCM
Single high-risk condition. Often the right call for specialists: cardiology HF panel, nephrology CKD panel, endo T2DM panel.
99424994259942699427
BEHAVIORAL HEALTH
BHI & CoCM
General BHI and the Psychiatric Collaborative Care Model. Time-based codes with a registered behavioral health manager and psychiatric consultant.
99484994929949399494
TRANSITIONAL CARE
TCM
Post-discharge management — 30-day window starting day of discharge. Contact within 2 business days, face-to-face within 7 or 14.
9949599496
ADVANCE CARE PLANNING
ACP
Advance Care Planning sessions — captured with the content discussed, who was present, and the patient's decision, then attested as a billable visit. Willowbridge tracks each patient's last ACP and flags when a refresh is due.
9949799498
SDOH & CHI
Social & community health
SDOH risk assessment and Community Health Integration. The new codes from the 2024 PFS that pay for actually addressing housing, food, and transportation.
G0136G0019G0022
The killer feature

A claim is only as good as the day someone asks about it.

Every billable period Willowbridge signs has a complete, contemporaneous audit packet attached. Not a PDF you generated after the fact — a chained, timestamped record of who did what, when, and on which version of the care plan. If your MAC opens a TPE or sends an ADR, your response is already written.

  • Activity log is append-only and signed — entries can't be backdated or edited silently.
  • Care plan version is pinned to each calendar month so the right document defends the right claim.
  • Consent capture, including the date and modality, lives on the patient timeline forever.
  • One-click TPE / ADR response export — paginated, indexed, with a cover sheet your compliance lead can sign.
AUDIT PACKET · ID 99490-EM-04-2026

Edith Marsh · April 2026 · CCM 99490

Charge handed to athena May 02 · NPI ·········· · sample data
Patient consent on file
Signed 2024-01-12 · verbal, witnessed by MA Aoki RN
v1.0
Comprehensive care plan in place
Reviewed 2024-12-14 · co-signed Velasquez MD
v3.2
Two+ chronic conditions documented
I10 · I50.32 · E11.9 · pulled from problem list
22 min cumulative non-face-to-face time
14m phone (Aoki RN) · 6m chart review (Velasquez MD) · 2m coordination (Pinkham PharmD)
≥ 20 min
Rendering provider co-signature
Diego Velasquez, MD · 2026-05-01 16:42 EDT
SHA-a91f
Place of service · modality
POS 11 office · phone (95) · no F2F required for 99490
CLAIM TOTAL
$64.42
Export · PDF
For patients · for retention

A care plan your patient actually reads.

Every enrolled patient gets a portal at demo.willowbridge.app/p/<token> — no app to download, no password to forget. It shows the goals you agreed on, the medications they're taking, the team behind them, and a one-tap check-in that flows directly back into your worklist.

  • Plain-language goals
    The same goals you set in the care plan — rewritten in the patient's voice, with "why this matters" sourced from the clinical record.
  • Their team, not "your provider"
    PCP, navigator, pharmacist — by name and face, with the right one to call for the right question.
  • One-tap check-ins
    Symptom or vitals updates that flow into the worklist and start an encounter if the navigator needs to follow up.
Willowbridge
Riverbend Family Medicine
HELLO EDITH · MAY 2026

Your plan for taking good care this season.

Three goals, five medications, one team — kept up to date after every visit.

YOUR TEAM
DV
Diego Velasquez, MD
Your primary care provider
MA
Maya Aoki, RN
Your navigator — call anytime
SP
Sara Pinkham, PharmD
For medication questions
THIS SEASON'S GOALS
1
Bring blood pressure under 135/80 by July
Target: average 7-day reading
2
Daily weights, call if up 3 lb in 2 days
For your heart failure
How are you today?
A quick check-in helps Maya keep things current.
The economics

What you're already eligible for. What you're leaving on the table.

Most primary care panels enrolled in CCM bill roughly half the months they're eligible. The math at scale is hard to ignore. Drop your numbers in — the model uses 2026 PFS national rates and conservative enrollment factors.

The Medicare panel you have today.

Adjust the numbers to your practice. The breakdown updates in real time. CCM is the easy entry point — most panels see this revenue captured within the first 90 days.

Defaults: 35% of Medicare patients have ≥ 2 chronic conditions and meet CCM eligibility · 60% consent and stay enrolled after first month · $85/mo blends 99490 + add-ons + RPM mix.
Eligible patients 280
Enrolled & consented 168
Monthly captured revenue $14,280
Annual captured revenue $171,360
Net new — captured by Willowbridge $171,360
Estimate assumes you're not currently billing CCM at scale. If you are, talk to us — we can model the lift from incremental capture and audit-driven recovery separately.
Pricing

Performance-based pricing. You pay for the care you capture.

Most care-management vendors charge a five-figure implementation fee, a per-provider license, and a per-patient PMPM whether or not you ever bill. Willowbridge charges none of that. There's one fee, and it applies only to billable care you actually capture.

No implementation
$0
No setup or onboarding fees. We get your practice live — patients, programs, and workflow — at no upfront cost.
No per-provider fee
$0
No seat licenses. Add every clinician, navigator, and biller on your team — the price doesn't change.
No per-patient base
$0
No PMPM and no monthly minimum. You're never billed for a patient who isn't generating billable care this month.

The one fee: a small per-patient charge that applies only when a patient qualifies for a billable service that month. No qualifying billable care, no charge — your cost scales with what you capture, and nothing else.

athenahealth Marketplace

Built for athena. Listed on the Marketplace.

Willowbridge is purpose-built for athenahealth practices. Sign in once, install Willowbridge from the athena Marketplace, and your care-management team starts working the panel the same day. Notes land in the chart on the date of service. Charges hand off to athena's billing pipeline as structured charge entries — no separate clearinghouse, no PDF shuffle, no new biller to train. Your existing athena workflows for revenue, payments, and reconciliation stay exactly where they are.

athena-native, standards-based

Willowbridge installs from the athenahealth Marketplace. Authentication is athena OAuth; clinical reads and document write-back are FHIR R4 (US Core); charges flow through athena's Charge API. Device readings flow in through whichever cellular hub or phone-bridged health store the patient already uses — nothing new for them to set up.

What flows to athena

athena owns the bill. Willowbridge owns the proof.

  • DocumentReference Signed encounter notes, care plans, ACP attestations, and AWV checklists land in the chart attached to the date of service.
  • Charge entry Structured charges (CPT, units, dx pointers, rendering provider, place of service) handed to athena at sign-off. athena bills the payer through your existing setup.
  • CarePlan Versioned care plan exposed back to athena so any provider in the chart sees the current copy.
  • Observation RPM device readings posted as flowsheet observations, not PDFs.
  • Provenance Every write carries a signed Provenance resource — Willowbridge's audit log is the chart's audit log.

athena Marketplace listing in progress. Production rollout is per-practice as the matching SMART scopes are enabled on your athena tenant.

Security & compliance

The boring infrastructure that lets you sleep at night.

A signed BAA is in place before any patient data touches the system. The encryption, tenant isolation, and audit log below are built to hold up under an actual payer audit — not just to look right in a security questionnaire.

✓ BAA on file

Signed before any patient data flows.

A standard Business Associate Agreement, executed during onboarding. The system won't accept real patient data from your EHR until it's in place.

✓ Encryption at rest

A stolen backup reads as noise.

Patient data is AES-256-GCM encrypted on disk, with keys managed by AWS KMS. The most sensitive bits — multi-factor seeds, EHR API tokens, device-pairing secrets — get a second layer of encryption on top, so a snapshot of the raw database reveals nothing on its own.

✓ Tamper-evident audit log

Nobody — including us — can quietly edit history.

Every read and write goes to an append-only log, chained with SHA-256 so any tampering invalidates everything after it. Exports are cryptographically signed, and the verifier is open source — your auditor can confirm a record is genuine without taking our word for it.

✓ Tenant isolation

Your practice's data lives behind its own wall.

Each practice's records are walled off at the Postgres database itself, not just in the application code. If a bug in our app ever asked for the wrong practice's records, the database would refuse to return them.

✓ U.S.-hosted

U.S.-hosted, U.S.-processed.

Runs in a U.S. AWS region, with backups encrypted and kept inside the U.S. No offshore processor ever touches patient data.

◷ Compliance roadmap

No badges we haven't earned.

SOC 2 Type II is on the roadmap — not certified yet, and we won't pretend we are. Ask under NDA and we'll walk you through exactly where we are and what's left.

Common questions

Questions practices ask first.

Who actually bills the claim — athena or Willowbridge?

athena bills. Willowbridge produces the structured charge (CPT, units, dx pointers, rendering provider, place of service) at sign-off and hands it to athena's Charge API. From there it goes through your existing athena billing setup — same payer connections, same posting, same reconciliation. No new clearinghouse, no new biller to train, no PDF shuffle between systems. Reimbursement lands in your account, where it already does.

How is the time substantiated if it's spread across multiple staff in one month?

Every encounter is stamped with the performing staff member, their role, the activity type (phone call, chart review, secure message, video visit), the patient, and start/end timestamps. The chronological log is append-only and hash-chained. At month-end, the rendering provider reviews the billing period and signs an attestation that includes the CMS-required general-supervision affirmation; the signature is cryptographically bound to the period (Ed25519, per-provider key) so a payer can independently verify it later. The cumulative minutes lock to that signature — nothing edits the period after approval.

What does an audit response actually look like?

One click on the billing period builds a single paginated PDF: cover sheet, eligibility, patient consent, the care plan pinned to the date of service, the chronological time log, the signed clinical note, and the provider attestation. That's the document you fax or upload to your MAC for an ADR or TPE — no unzipping, no assembling loose files. It's drawn from the snapshot frozen the moment the period was signed, so it can't drift from what athena billed on your behalf. The same records also come as a verifiable archive — every file fingerprinted into a signed manifest, with an open-source verifier (packages/audit-verify) — for the rare payer or auditor who wants to confirm the chain themselves. The audit packet (the work) and athena's claim + 835 (the bill) cross-reference cleanly by patient + date of service + CPT.

How long does implementation take?

Install Willowbridge from the athenahealth Marketplace, enable the matching SMART scopes on your tenant, and your team is working the panel the same day. Chart write-back and charge handoff switch on as soon as the OAuth handshake completes — no separate clearinghouse onboarding, no SFTP credentials, no 837 mapping conversations. Add a short training session for the navigator team and you're running.

Can we run CCM, RPM, BHI, and TCM on the same patient?

Yes, with the right modifier and place-of-service interactions. Willowbridge knows the rules: CCM and PCM aren't billable in the same month; CCM and TCM can't overlap the TCM 30-day window; RPM and CCM minutes can't double-count the same activity. The worklist tells your team which program any given encounter is contributing to before the encounter starts.

What about FQHCs and rural health clinics?

Yes. CMS sunset G0511 at the end of 2024 — FQHCs and RHCs now bill the standard care-management codes directly (99490 / 99491 / 99487 CCM, 99424–99427 PCM, 99484 BHI, 99457/99458 RPM). WillowBridge runs the same workflow your non-FQHC peers use; FQHC/RHC payment lands through your PPS / AIR rate the same way the bundled code used to.

What does it cost?

Performance-based — you pay only for billable care you actually capture. There's no setup or implementation fee, no per-provider license, no per-patient base fee, and no monthly minimum. The only charge is a small per-patient fee that applies when a patient qualifies for a billable service and the month closes; if a patient doesn't qualify that month, there's no charge. We don't take a cut of your reimbursement and don't charge for the audit packet. Reach out for a walkthrough sized to your panel.

Book a demo

See Willowbridge in action. 20 minutes, no prep required.

A live walkthrough with a Willowbridge clinical lead. We'll show you the worklist, the audit packet, and the billing flow on a demo tenant — no data of yours, no setup on your end. Bring your questions about programs, workflow, or fit.

Or email [email protected].