An independent cardiology practice, one interventional cardiologist and one physician assistant, in two ZIP codes where 76.0% and 84.2% of residents are 65 or older. The panel is almost entirely Medicare, and the months between office visits are unbilled today. This is the case for a remote care service line the practice supervises and bills while CoachCare staffs and runs it: transitional care at every cardiac discharge, remote monitoring and principal care management for the months after, with no capital and no new hires. Net to the practice is positive from month 2, and the practice keeps 42.85% of net reimbursement over 24 months.
Year 1 margin 41.13%, Year 2 43.66%. Enrollment begins in month 1; month 1 runs −$5,414 while setup posts against a small census, and the practice is positive from month 2 onward. The headline is 651 unique patients; the enrollment chart shows 994 active program enrollments, because a patient on both programs is one patient and two enrollments.
One interventional cardiologist and one physician assistant, two offices, each beside the hospital where the practice admits, in retirement communities where nearly every patient who walks in is on Medicare. The clinical work of a much larger cardiology group happens here every day. What does not happen yet is billing for the months between visits.
Heart failure in 25% of them, atrial fibrillation in 37%, chronic kidney disease in 44%, diabetes in 30%, ischemic heart disease in 43%, and hypertension at the 75% ceiling CMS publishes. A risk score of 1.50 against a national 1.00. That is the traditional Medicare half; with Medicare Advantage, the practice cares for about 2,400 Medicare patients, roughly 1,000 of them traditional Medicare.
In CY2024 Medicare paid the practice for remote interrogations of pacemakers, defibrillators and loop recorders on roughly a hundred patients, worked on a calendar, documented and billed on a monthly cadence, and for warfarin management on 31 patients across 353 services. A remote monitoring line is the same operating pattern with a blood pressure cuff and a scale in place of the implanted device.
A heart failure or atrial fibrillation patient is seen every three to six months. In the months between, the weight trend, the blood pressure, the medication titration and the phone calls go unmonitored and unpaid. In CY2024 the practice billed no remote monitoring, transitional care or care management line at meaningful scale. That is where 99453 through 99458, 99470 and 99426/99427 apply.
In ZIP 85351, Sun City, 76.0% of residents are 65 or older; in 85375, Sun City West, it is 84.2%. Median ages are 72.6 and 74.7, and 83 to 87 percent of residents carry public coverage. About 44,000 people aged 65 and over live in the two ZIP codes alone. Maricopa County's Medicare population is 51.5% Medicare Advantage as of September 2026, and Medicare Advantage plans concentrate in age-restricted retirement communities. Medicare Advantage plans reimburse at or above the Medicare rate as a floor; individual contracts set their own terms for the care-management code families. The forecast on this page is priced at the Medicare rate throughout.
The AHCCCS and commercial slice of the panel is small here, 2.4% of the practice's Medicare patients are dually eligible, and it sits outside the forecast. AHCCCS covers remote patient monitoring, with 99091, 99445, 99453, 99454, 99457 and 99458 on its 2026 Telehealth Code Set, and Arizona's parity statute defines telehealth to include remote patient monitoring. Both are scoped separately once the Medicare line is running.
The practice admits to Banner Del E. Webb Medical Center and Banner Boswell Medical Center. Between them the two hospitals see about 2,600 heart failure index admissions in a two-year window. On the CMS excess-days measure for heart failure, Del E. Webb runs −19.8 acute-care days per 100 discharges against expected, better than the national rate. Boswell carries excess readmission ratios above 1.0 on heart failure (1.0647) and heart attack (1.0917) in the FY2026 Hospital Readmissions Reduction Program file. The care inside both buildings is not the problem. The thirty days after the patient goes home are, and those are the days this service line is built around: contact within two business days, a visit inside 7 or 14 days, a cuff and a scale transmitting daily, and a care manager who sees a three-pound weight gain on Tuesday and has the diuretic adjusted before Friday. A cardiology practice that runs that cadence is the referral relationship both hospitals want more of.
Fewer acute-care days after a heart failure discharge than expected. The practice's inpatient work, echo lab and catheterization cases run here.
Above 1.0 on both cardiac measures in the program file that sets payment. A transitional care and monitoring cadence at every cardiac discharge is the intervention the measure rewards.
At a 20% annual admission rate across the monitored census. A cohort where a quarter of the patients carry heart failure admits well above that; at 40% the figure is about 127.
At $15,000 per admission. None of it is in the Value Analysis below, which prices the fee-for-service codes only.
The same census, the same program, an admission rate closer to what a heart-failure cohort runs. The practice's own discharge data replaces both figures once the program is live.
Three billing families, one clinical workflow, one care team. A patient enters wherever they are, coming out of the hospital, newly decompensated, or overdue for real between-visit management, and stays on the same pathway. Two clinicians supervise it; CoachCare staffs it.
Noridian, Arizona statewide locality 03102-00, non-facility. Arizona has one fee-schedule locality, so both offices price the same.
| Code | What it covers | CY2026 rate | Cadence |
|---|---|---|---|
| 99496 | Transitional care management, high complexity, face-to-face within 7 days | $292.37 | Once per discharge |
| 99495 | Transitional care management, moderate complexity, within 14 days | $215.45 | Once per discharge |
| 99453 | Remote monitoring, patient set-up and education | $20.96 | Once per episode |
| 99445 | Device supply, 2–15 days of readings (new for CY2026) | $50.45 | Short window |
| 99454 | Device supply, 30 days of readings | $50.45 | Monthly |
| 99470 | Monitoring management, 10–19 minutes (new for CY2026) | $25.49 | Monthly |
| 99457 | Monitoring treatment management, first 20 minutes | $50.65 | Monthly |
| 99458 | Monitoring treatment management, each additional 20 minutes | $40.61 | Monthly |
| 99426 | Principal care management, clinical staff, first 30 minutes | $66.47 | Monthly |
| 99427 | Principal care management, clinical staff, each additional 30 minutes | $52.98 | Monthly |
| 99424 | Principal care management, physician or other qualified professional, first 30 minutes | $85.88 | Monthly, when the physician does the time |
| 99425 | Principal care management, physician or other qualified professional, each additional 30 minutes | $60.32 | Monthly, when the physician does the time |
CY2026 Physician Fee Schedule non-facility amounts for ZIP 85375 (Noridian JF, Arizona statewide locality), the basis the Value Analysis below is priced on. Medicare Advantage plans reimburse at or above the Medicare rate as a floor; individual contracts set their own terms for the care-management code families. The forecast bills the clinical-staff PCM codes; the physician codes are listed for the months the cardiologist personally carries the time.
CoachCare integrates with the practice's EHR in both directions. Enrollment flags and orders leave the chart; discrete vitals, care documentation, enrollment status and claim-ready output come back into it. Both clinicians stay in the chart they already use, and the practice's biller does not learn a new claim path.
Enrollment flags and trigger ordering sit in the clinical workflow. CoachCare's team enrolls the flagged patients on the practice's behalf, status shows in the chart in real time, and patients begin receiving services in under five days.
Device readings file as discrete vitals in the flowsheet, not as attachments. The care summary and evidence of care post to the chart monthly, which is what makes a time-based claim hold up under audit.
CoachCare generates the claim for every enrolled patient, every month, and hands it to the practice's billing workflow. The manual claim step a two-clinician practice would otherwise absorb never exists.
CoachCare runs live integrations with the major ambulatory EHR platforms and a custom HL7/FHIR interface for the rest. This forecast carries the interface at the custom tier: $4,000 one time, $150 a month and $1.50 per enrolled patient per month, all inside the financial summary below. Scope and vendor are confirmed in contracting.
The Value Analysis shows the program pays. This is the part that says it is safe, and that two clinicians see signal rather than five hundred readings a day. The routing is written into a charter the practice signs before the first device ships, and it follows CoachCare's Care Management standard operating procedures.
Chest pain, new shortness of breath, stroke signs, syncope, sudden swelling. CoachCare's urgent and emergent policy supersedes any practice-specific preference. If the patient refuses, the clinic is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician the practice names in the charter, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a clean symptom check closes the loop with a chart note and nothing else. The cardiologist's inbox is reserved for what needs a decision.
A recommended discharge goes to the clinic for instructions and is re-escalated every 30 days; the practice is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost. Discharge follows the same written criteria, with the clinic told every time.
Any emergency visit or hospitalization in the preceding 60 days triggers a fixed three-touch follow-up, and when the patient was admitted it is also the TCM episode. That cadence, on this panel, is where the 64 avoided hospitalizations over 24 months come from.
Reach the patient, identify what precipitated the event, reconcile medications against the discharge instructions, confirm the cuff and scale are transmitting.
Medication adherence confirmed, the triggers re-checked, education reinforced, the follow-up appointment with the practice confirmed.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + PCM stack: 1,920 Medicare patients in scope for Year 1 out of a Medicare panel of about 2,400, 2 referring clinicians (one interventional cardiologist and one physician assistant), one CoachCare-funded on-site enrollment specialist, Arizona statewide locality rates and the EHR interface. Transitional care is not in these numbers, and neither is the AHCCCS or commercial slice.
| Program | Net reimbursement | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM: devices, data and management | $906,950 | $508,991 | $397,959 |
| Year 1 / Year 2 | $338,031 $568,919 | $186,277 $322,714 | $151,754 $246,205 |
| PCM: principal care management | $612,330 | $319,588 | $292,742 |
| Year 1 / Year 2 | $152,248 $460,082 | $79,462 $240,127 | $72,786 $219,955 |
| Implementation, EHR interface and outreach | — | $39,747 | −$39,747 |
| 24-month total | $1,519,280 | $868,327 | $650,953 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the practice and never deducted from its margin. | |||
24-month practice margin: 42.85% of net reimbursement (Year 1 41.13%, Year 2 43.66%).
Year 1 is $201,645 net to the practice on $490,279 of net reimbursement; Year 2 is $449,308 on $1,029,001. Month 1 is −$5,414 as the one-time setup lands ahead of the ramp; monthly net is positive from month 2 onward.
Recurring professional-fee volume over 24 months, generated by the billing engine and handed to the practice's billing workflow.
Blood pressure, heart rate and weight, a continuous picture of the panel between visits, triaged before either clinician sees any of it.
About $0.95M in acute-care cost that never gets spent, at $15,000 per admission. Outside the forecast, and the start of the practice's own outcome record.
About 14,008 care-team hours of monitoring, outreach and documentation carried by the service line, not by a two-person clinical team.
Remote monitoring reaches its eligible pool of 504 in month 10, and principal care management reaches 490 in month 21. After that each census holds and its economics flatten. Your constraint is the size of the eligible population, not outreach capacity: 1,920 patients in scope, 75% of them eligible for monitoring and 85% for care management, at 35% and 30% acceptance. Every point of eligibility or acceptance the practice's own chart supports beyond these raises both ceilings directly, and the Scenario Explorer below shows by how much.
| Program | Enrollment ceiling | How it is defined | Month 24 |
|---|---|---|---|
| RPM | 504 | 1,920 in scope × 75% eligible × 35% acceptance · reached in month 10 | 504 |
| PCM | 490 | 1,920 in scope × 85% eligible × 30% acceptance · reached in month 21 | 490 |
| At month 24 | — | Active program enrollments = 651 unique patients | 994 |
Eligibility is set for a cardiology Medicare cohort. Year 1 lands at 591 unique patients and 793 program enrollments; the first 90 days run 29, 76 and 141 active enrollments.
| Enrollment staffing | 24-mo net reimbursement | Net to practice | Unique, M24 |
|---|---|---|---|
| Practice referrals and telephonic outreach only, no on-site specialist | $320,187 | $126,408 | 231 |
| One CoachCare-funded on-site specialist (this forecast) | $1,519,280 | $650,953 | 651 |
| Two CoachCare-funded on-site specialists | $1,806,421 | $781,038 | 651 |
A second CoachCare-funded specialist cannot raise either ceiling, but it reaches them sooner: $287,141 more net reimbursement (+18.9%) and $130,085 more net to the practice over 24 months. Without the on-site specialist, the practice's own referral flow and telephonic outreach produce $320,187, 79% below this forecast.
CoachCare operates as the service line's engine while the practice's cardiologist governs protocols and every clinical decision. Launch needs no new hires and no capital, and the transitional-care path produces cash before any device ships: 99495 and 99496 at every cardiac discharge from the two hospitals next door. On a two-clinician practice the point is that nothing here lands on the clinicians' calendar except the supervision they already provide.
Agree the escalation routing and who receives non-critical alerts. Pull the heart-failure, atrial-fibrillation and uncontrolled-hypertension cohorts out of the chart and confirm the enrollable list against the panel in this analysis.
Turn on the EHR interface, configure the time-capture and code mapping under the practice's own billing number, and run a claims test on the transitional care management path first.
The funded specialist starts in the practice's offices, working from the confirmed cohort list. Devices ship to enrolled patients. First readings arrive and the escalation engine goes live with the practice watching every route.
The census builds toward the curves in the analysis, and both programs reach their ceilings inside the second year. Blood-pressure control, titration documentation and post-discharge touches accumulate as retrievable reports, the outcome record every payer conversation will ask for.
The service line on this page runs on infrastructure already proven at national scale, and already running a few miles from the practice's front door.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs day to day on the CoachCare platform.
Programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims. The billing path is the part most remote-care programs get wrong, and the part a two-clinician practice can least afford to.
Over 100 million vitals recorded and 4 million+ care actions enabled.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposal is narrower than the headline. Here is what it does to the forecast on this page, priced at the Arizona statewide locality amounts the forecast itself uses rather than national averages.
The proposal reaches the remote-monitoring family only. Principal care management is not in it, and on this forecast PCM carries $612,330 of the $1,519,280 in 24-month net reimbursement. Its own amounts move by well under a point through the conversion factor, so $3,082 of the $89,295 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement, with the software platform, device logistics and program enablement priced separately, and an arrangement in which CoachCare manages the staffing while the practice owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. A practice that builds the documentation and outcome-reporting habit into its first year of operation is the practice that can take that payment when it arrives.
Three numbers, each smaller than the last, because each one sits on a larger base. Both bars are drawn on one shared dollar scale, so the red can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Noridian Arizona statewide locality (03102-00) amounts, non-facility, on this forecast's own billing mix. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B, so the movement can be read without a locality in the way. The repricing above uses Arizona statewide locality amounts; the two bases do not reconcile to the dollar, by design.
| In scope: remote monitoring | ||||
|---|---|---|---|---|
| Code | What it pays for | CY2026 | CY2027 | Change |
| 99453 | Setup and patient education | $21.71 | $20.03 | −7.7% |
| 99445 | Device supply, 2–15 days | $52.11 | $41.38 | −20.6% |
| 99454 | Device supply, 16–30 days | $52.11 | $41.38 | −20.6% |
| 99457 | Treatment management, first 20 minutes | $51.77 | $49.59 | −4.2% |
| 99458 | Treatment management, each additional 20 minutes | $41.42 | $40.39 | −2.5% |
| 99470 | Treatment management, first 10 minutes | $26.05 | $20.69 | −20.6% |
| Not in scope: principal care management | ||||
| 99426 | Principal care management, first 30 minutes (clinical staff) | $67.80 | $67.00 | −1.2% |
| 99427 | Principal care management, each additional 30 minutes | $54.11 | $54.52 | +0.8% |
| 99424 | Principal care management, first 30 minutes (physician) | $87.51 | $84.40 | −3.6% |
| 99425 | Principal care management, each additional 30 minutes (physician) | $61.46 | $59.11 | −3.8% |
The device-supply and short-treatment codes are held to a one-year maximum reduction by section 1848(c)(7) of the Act, which phases any decrease of 20 percent or more over two years. CY2027 is the capped year; the remainder of the crosswalk lands no earlier than CY2028.
The comment period on CMS-1848-P closed September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare is leading advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.