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Opportunity Knocking — Empanelment, COVID-19 and Telehealth

By Trudy Bearden, PA-C, MPAS

February 17, 2021

Do you know what it is? Probably not if you’re not “in” primary care. You may know the patient side of empanelment, though. If you have a primary care provider (PCP), it usually means you have been empaneled to that provider.


Do you know what it is? Probably not if you’re not “in” primary care. You may know the patient side of empanelment, though. If you have a primary care provider (PCP), it usually means you have been empaneled to that provider.

Empanelment is a foundational component of primary care and is essential in population health management. In 2019, the People-Centered Integrated Care collaborative, participants from 10 countries developed an overview of empanelment and a comprehensive definition:

Empanelment is a continuous, iterative set of processes that identify and assign populations to facilities, care teams, or providers who have a responsibility to know their assigned population and to proactively deliver coordinated primary health care.

That definition is accurate and comprehensive, but we must appreciate the recent, succinct statement by my Empanelment Learning Exchange colleague Elizabeth Wala, Global Advisor, Health and Nutrition at Aga Khan Foundation: “Empanelment is grouping patients under providers.”


As a primary care clinician and health care consultant, I have been thinking hard since April 2020 about the importance of empanelment, telehealth and the COVID-19 pandemic. Just to be clear, I’m using the term telehealth as defined by the discrete set of services described by the Centers for Medicare & Medicaid Services (CMS) List of Telehealth Services. Similarly, there are amazing opportunities for other remote services, including chronic and principal care management, remote patient monitoring, virtual check-ins and more that lend themselves to applying empanelment to improve health and well-being. Maybe for another blog …

Most clinicians use electronic health records (EHRs) these days and can run or request reports on their patient panels to identify which patients may need health care services. Empanelment provides each clinician with a list of names of their patients along with additional information such as age, date last seen, diagnoses, preventive and chronic care that is due and more. Here are some of the ways we can leverage empanelment and telehealth to keep people safe, expand access and capture revenue.

Check in on the unseen and unknown. Empanelment is not just about those who seek health care services from us, although that’s often how it starts. The beauty of empanelment is that there should be no people on a clinician’s panel who are “unseen and unknown.” However, the Centers for Disease Control and Prevention (CDC) estimates that 41% of U.S. adults have delayed or avoided medical care during the pandemic because of concerns about COVID-19, which presents us with an opportunity.

Identify who hasn’t been seen in the past 6-12 months for each clinician’s panel.
Have clinicians go through the list and identify who should receive a check-in call and who should be scheduled for a telehealth visit. There may not be reimbursement for those check-in calls; although there are service codes and reimbursement for virtual check-ins, those check-ins are technically supposed to be initiated by the patient.
Conduct advance care planning. If ever there was a time! And it can be accomplished by telehealth — using codes 99497 (~$85) and 99498 (~$74) — with decent reimbursement. Start with all individuals 65 and older in your panel.

Ensure high-risk patients know about telehealth. Now more than ever, know who your top 5-10% highest risk patients are, including those at highest risk for adverse COVID-19 outcomes. These patients will benefit from having telehealth as an option perhaps more than any other population in your practice.

Conduct targeted outreach to the top 5-10% high-risk patients to schedule a telehealth visit, if needed or to let them know about telehealth as an option.
Address chronic and preventive gaps in care. As people delay care and as team-based care and pre-visit planning workflows seem to fall by the wayside, I am concerned that missed and delayed diagnoses will soar, which is both terrible for individuals and families, but is also one of the most common reasons for malpractice claims.

Use panel data to identify who’s due for what:
Chronic conditions, e.g., office visits, tests, vaccines, prescription renewals
Preventive services, e.g., well-child visits, colorectal cancer screening (CRC), vaccinations
Advise patients about the services that are due by phone, text or letter and schedule those for telehealth visits, if needed.
Consider this a call to action for primary care practices! If you’re not already leveraging empanelment to optimize telehealth, expand access, make sure people are doing okay and keep people safe, what can you do by next Tuesday to up your game?

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