Transitional care management outreach guide

When a patient leaves a hospital or a skilled nursing facility, the days that follow are a handoff. Medicare pays for a defined service built around that handoff, transitional care management, and the service has a clock: a contact with the patient within 2 business days of discharge and a face-to-face visit within a set number of days. For a practice, that turns outreach into an operations problem. You need to know the patient was discharged, reach them fast, say the right things on the first call, describe the cost honestly and keep your relationships with hospitals clear of anything that looks like payment for patients. This guide works through each of those using the CMS booklet, the hospital discharge planning rule, the Medicare.gov page patients see and the federal privacy, telephone and kickback rules.

Two related topics have their own guides and are not repeated here. Monthly care coordination for patients with two or more chronic conditions, including the consent items CMS lists, is covered in our chronic care management guide. How the Anti-Kickback Statute, the physician self-referral law and their safe harbors apply to referral relationships in general is in our patient and physician referrals guide.

This is general information, not legal or medical advice. Sources cited were checked on October 30, 2026: the CMS Medicare Learning Network booklet Transitional Care Management Services (MLN908628, August 2025), the Medicare.gov page Transitional care management services, the Medicare.gov page Doctor and other health care provider services, 42 CFR 482.43 (hospital discharge planning, as amended at 89 FR 94592, November 27, 2024), 45 CFR 164.501 and 164.506, 47 CFR 64.1200, 42 U.S.C. 1320a-7b(b), 42 CFR 1001.952(ee), 15 U.S.C. 45 and 52, and the FTC policy statements on deception and advertising substantiation. Billing codes, payment amounts and telehealth rules change with each year’s Physician Fee Schedule and are not covered here. Scope of practice for clinical staff is set state by state.

What transitional care management is, in the words CMS uses

The CMS booklet says Medicare may cover transitional care services during the 30-day period that begins when a physician discharges a Medicare patient from an inpatient stay and continues for the next 29 days, and that these services help eligible patients transition back to a community setting. It lists the required elements as supporting the patient’s transition to a community setting, accepting the patient at the time of discharge without a gap in service, taking responsibility for the patient’s care, and moderate or high complexity medical decision making.

The 30-day period starts on the day of discharge from one of these settings, as the booklet lists them:

Inpatient acute care hospital.
Inpatient psychiatric hospital.
Inpatient rehabilitation facility.
Long-term care hospital.
Skilled nursing facility.
Hospital outpatient observation or partial hospitalization.
Partial hospitalization at a community mental health center.

The patient must return to a community setting, which the booklet describes as a home, a domiciliary such as a group home or boarding house, a nursing facility or an assisted living facility. Medicare.gov tells patients the same story in plainer words: the health care provider managing the transition works with the patient, family, caregivers and other providers to coordinate and manage care for the first 30 days after the patient returns home, and the patient will be able to get an in-person office visit within 2 weeks of returning home.

Physicians of any specialty can provide the service, as can nurse practitioners, physician assistants, clinical nurse specialists and certified nurse-midwives who are legally authorized and qualified in their state. The booklet also says only one physician or other practitioner may report the service for a patient during the period. That matters for outreach: if a specialist, a hospitalist group and the primary care office all call the same patient about the same 30 days, the patient gets three calls and only one office can bill. A short conversation with the specialists you share patients with about who takes the transition saves the patient that confusion.

The clock: what has to happen and when

The booklet sets out three things that have to happen inside the 30 days, and each one shapes the outreach.

The first is the interactive contact. The practitioner, or clinical staff under their direction, must contact the patient or caregiver by phone, by email or face to face within 2 business days after discharge. The booklet says the contact must be made by clinical staff who can address the patient’s status and needs beyond scheduling follow-up care. A front desk call that only books a slot does not meet that description. If the first attempts fail, the booklet says the service may still be reported after two or more unsuccessful separate attempts made in a timely manner, as long as the other requirements are met, and that the attempts must be documented in the medical record and contact attempts should continue until they succeed.

The second is the face-to-face visit. The booklet ties the visit deadline to the level of medical decision making: within 14 calendar days of discharge for moderate complexity and within 7 calendar days for high complexity. If the visit does not happen within the required timeframe, the booklet says the practice cannot bill the service. It also says the required visit cannot take place on the same day the same practitioner reports discharge day management.

The third is medication reconciliation and management, which the booklet says must be provided on or before the date of the face-to-face visit. Between those points sit the non-face-to-face services, such as reviewing discharge information, following up on tests, arranging community resources and educating the patient and caregiver.

For scheduling, that means the visit slot has to be held before the patient calls. A practice that offers transitional care needs open appointments inside the 7 and 14 day windows every week, and a first-call script that books into them, not a general request to call back.

Knowing the patient was discharged

Outreach within 2 business days only works if the practice hears about the discharge. The hospital discharge planning rule helps here. Under 42 CFR 482.43(b), a hospital must discharge the patient along with all necessary medical information about the patient’s current course of illness and treatment, post-discharge goals of care and treatment preferences, at the time of discharge, to the post-acute providers and to the practitioners responsible for the patient’s follow-up care.

The HIPAA Privacy Rule allows that flow. Under 45 CFR 164.506(c)(2), a covered entity may disclose protected health information for the treatment activities of a health care provider, so a hospital sending discharge information to the practice that will see the patient next does not need a patient authorization for that purpose.

Practical ways to make sure the information reaches the right desk:

Ask the case management or discharge planning department at each hospital and facility your patients use where they send discharge information for your practice, and give them one fax number, direct address or inbox that someone checks every business day.
Ask patients at routine visits to tell the hospital the name of their primary care practice if they are admitted, and to call the office when they get home.
Name one person on the clinical team who reads incoming discharge notices each morning and starts the 2 business day clock.
Keep the discharge date in the record from the moment the notice arrives, because the booklet lists the discharge date, the first contact date, the visit date and the level of medical decision making as the minimum documentation.

Hospital and facility relationships: what not to trade

A steady flow of discharged patients is valuable, and that is exactly why the Anti-Kickback Statute matters here. Under 42 U.S.C. 1320a-7b(b), it is a felony to knowingly and willfully solicit, receive, offer or pay any remuneration in return for referring, or to induce the referral of, an individual for services paid by a federal health care program, or for arranging for or recommending those services. The statute covers remuneration paid directly or indirectly, in cash or in kind.

In a transitional care setting, these are the arrangements to take to a health care attorney before you agree to them:

A hospital, facility or outside company offering the practice a list of discharged patients, or a regular feed of names, in exchange for a fee, a share of billing or a promise to send patients back.
The practice paying anyone per patient handed off, per visit booked or per service billed.
A hospital offering free staff, such as a nurse navigator working in your office, free software or free services tied to the patients you see.
Any agreement that the practice will refer its patients to a particular hospital, facility or home health agency in return for receiving discharges.

Not every arrangement between a hospital and a practice is unlawful. The regulations at 42 CFR 1001.952 set out safe harbors, and paragraph (ee) covers care coordination arrangements, which protect in-kind remuneration exchanged within a value-based arrangement only if every one of the standards in that paragraph is met. Whether an arrangement fits is a question for counsel, and the analysis is in our referrals guide. The routine hospital duty to send discharge information under 482.43(b) needs no payment from anyone, so a practice does not need to offer anything to receive it.

The rule also protects the patient’s choice. Under 482.43(d)(2), a hospital must inform patients of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and must not specify or otherwise limit the qualified providers available to the patient. That paragraph is written about post-acute services such as home health and skilled nursing, but the principle is a good test for any arrangement you are offered: if it depends on steering patients away from their own choice, do not sign it.

The first call is a care call

Under the HIPAA Privacy Rule, the definition of marketing in 45 CFR 164.501 leaves out communications for the treatment of an individual by a health care provider, including case management or care coordination, unless the covered entity receives financial remuneration in exchange for making the communication. A clinical call from the practice to its own patient about the patient’s discharge and follow-up care fits that exclusion. If a third party pays the practice in connection with the call, the exclusion falls away, which is one more reason to keep payment out of these relationships.

The first call should do clinical work. The booklet lists services that auxiliary personnel may provide under general supervision, and those make a good outline for the call:

Communicate with the patient about how they are doing since discharge.
Assess and support treatment adherence, including medication management.
Communicate with agencies and community service providers the patient uses.
Educate the patient, family, guardian or caregiver to support self-management and activities of daily living.
Identify community and health resources and help the patient and family access needed care and services.

Book the face-to-face visit on the same call, and tell the patient to bring every medication container and the discharge paperwork so medication reconciliation can happen on or before that visit. Keep the call about the patient. A post-discharge call that turns into a pitch for an unrelated cash-pay service is no longer a care coordination call, and it would need its own review under the marketing definition.

A caregiver may be the right person to reach, and the booklet allows the contact to be with the patient or their caregiver. Before discussing details with a family member, check what the patient has agreed to and what the record says about who may be involved in their care.

Calls, texts and the federal telephone rules

The interactive contact in the booklet is a two-way conversation, so a live call from clinical staff is the natural fit. Automated calls and texts still have a place, for example a text asking the patient to call back or confirming the visit time. The Telephone Consumer Protection Act rules at 47 CFR 64.1200 set the limits. Under 64.1200(a)(1)(iii), a call to a cell phone using an automatic telephone dialing system or an artificial or prerecorded voice needs the called party’s prior express consent unless it is made for emergency purposes. Under 64.1200(a)(2), an automated call that includes an advertisement or constitutes telemarketing needs prior express written consent, except for a call that delivers a health care message made by or on behalf of a HIPAA covered entity or its business associate.

For prerecorded calls to a residential line, 64.1200(a)(3)(v) allows health care messages from a covered entity or business associate without consent only if the caller makes no more than one call per day to each patient, up to three calls a week, and honors opt-out requests. A recorded voicemail does not count as the interactive contact, so use automation only to prompt a callback and keep the clinical conversation live.

Keep voicemails and texts free of diagnoses and hospital details. “This is the care team at your doctor’s office. Please call us back at this number about your follow-up after your recent stay” says enough. Our guide to texting patients covers consent and content for appointment texts in more depth.

Cost wording

The Medicare.gov page on transitional care management says that after the patient meets the Part B deductible, the patient pays coinsurance for these services, and tells the patient to ask the doctor or provider how much it will cost. The Medicare.gov page on doctor services describes the general rule: after the Part B deductible, the patient pays 20 percent of the Medicare-approved amount, and pays nothing for certain preventive services when the provider accepts assignment.

That gives the practice two rules for the first call and for any printed material:

Do not call the follow-up call, the visit or the 30 days of coordination free, included or no cost. The Medicare.gov page says coinsurance applies after the deductible.
When a patient asks what it will cost, have the billing team answer with the patient’s own coverage in front of them. For patients in a Medicare Advantage plan or with supplemental coverage, the answer depends on the plan.

Copays are not something to waive as a way of getting patients to agree. Routine waivers of cost-sharing raise their own federal questions, which our chronic care management guide covers.

What the website and printed material can say

A page on your website or a handout given at discharge can describe the service. Describe it the way Medicare.gov does: help returning home after a stay in a hospital or skilled nursing facility, a care team that reviews the information from the stay, help with medications, arranging follow-up care and community resources, and an in-person visit within 2 weeks of returning home.

Claims about results need more care. Section 5 of the FTC Act, 15 U.S.C. 45, prohibits deceptive acts or practices, and section 12, 15 U.S.C. 52, prohibits false advertisements likely to induce the purchase of services. The FTC Policy Statement Regarding Advertising Substantiation says that advertisers must have a reasonable basis for objective claims before they make them. A statement that your program prevents readmissions, shortens recovery or keeps patients out of the hospital is an objective claim about outcomes. Unless you hold data that supports it for your own patients, leave it out and describe what the team does instead.

Access claims need the same discipline. “Seen within 7 days of discharge” is a promise about your schedule. Make it only if your schedule keeps those slots open every week, and say how the patient arranges it.

Illustration: a discharge notice on a Thursday

Illustration: a primary care practice receives a discharge summary on Thursday morning for a patient sent home from a hospital the day before after an admission for heart failure. The nurse who reads discharge notices that morning logs the discharge date, sees that the 2 business day window runs through Friday, and calls the patient at noon. The patient’s daughter answers. The record shows the patient listed her as someone who may be involved in care, so the nurse talks with both, goes over how the patient feels, the new medications on the discharge list and the follow-up appointments the hospital recommended, and books a visit with the physician for the following Tuesday. The nurse asks them to bring every medication bottle. When the daughter asks whether the visit is covered, the nurse says Medicare covers the service and coinsurance may apply after the deductible, and transfers her to billing for the patient’s own numbers.

Illustration: a hospital’s outreach team offers the same practice a weekly list of its discharged patients who list the practice as their doctor, and asks in return that the practice send its patients needing imaging to the hospital. The office manager declines the exchange, asks the hospital’s case management department to send discharge information directly as part of discharge planning, and sends the referral proposal to the practice’s health care attorney.

Checklist

Each hospital and facility your patients use knows where to send discharge information for your practice, and someone checks that inbox every business day.
One named clinical staff member starts the 2 business day clock from each discharge notice and logs the discharge date.
The first contact is made by clinical staff who can address the patient’s status and needs, not only scheduling, and every attempt is documented.
Visit slots inside the 7 and 14 day windows are held open every week.
Medication reconciliation is planned for on or before the face-to-face visit, and patients are asked to bring their medications.
The practice has agreed with shared specialists which office takes the transition, since only one may report the service.
No hospital, facility or company is paid per patient, per visit or per service, and any offer of free staff, software or patient lists has gone to counsel.
Voicemails and texts leave out diagnoses and hospital details, and automated messages have been checked against 47 CFR 64.1200.
No material calls the service free, and cost questions go to billing with the patient’s coverage in hand.
Website and handout claims describe what the team does and make no outcome claims the practice cannot support.

How we help

We build websites, local search, Google Ads and AI front desk tools for independent practices and health businesses. For a practice offering transitional care, that means a website page that describes the service and its costs the way Medicare.gov does, call scripts that put the clinical questions first, and inquiry flows that send post-discharge calls straight to the clinical team and cost questions to billing. Our tools are built with HIPAA in mind. We confirm in writing what a BAA covers before any patient information flows through a tool, and if it is not covered, we do not route patient information through it. We are not a healthcare provider and we do not give legal or medical advice. We do not sell lead lists and we do not pay for referrals. For the wider rules, see our healthcare marketing rules hub.

How soon after discharge must the practice contact the patient?

The CMS booklet says the practitioner or clinical staff must contact the patient or caregiver by phone, email or face to face within 2 business days after discharge. Two or more timely, documented, unsuccessful attempts can count if the other requirements are met.

When does the face-to-face visit have to happen?

The CMS booklet ties it to the level of medical decision making: within 14 calendar days of discharge for moderate complexity and within 7 calendar days for high complexity. Without a timely visit the service cannot be billed.

Can the front desk make the first call?

The booklet says the interactive contact must be made by clinical staff who can address the patient’s status and needs beyond scheduling follow-up care. A call that only books an appointment does not meet that description.

Is the post-discharge call HIPAA marketing?

Under 45 CFR 164.501, communications for treatment, including case management and care coordination, are not marketing unless the practice is paid by a third party to make them. A clinical follow-up call to your own patient fits that exclusion.

Can we tell patients transitional care is free?

No. The Medicare.gov page says that after the Part B deductible the patient pays coinsurance for these services. Send cost questions to billing with the patient’s coverage in hand.

Can a hospital give us a list of its discharged patients?

A hospital must send necessary medical information to the practitioners responsible for follow-up care under 42 CFR 482.43(b). A list offered in exchange for payment or for referrals back raises Anti-Kickback Statute questions, so take any such offer to counsel.

Sources

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