Medicare already pays monthly for managing heart failure, atrial fibrillation, coronary artery disease and hypertension between visits — a physiologic layer this group leaves unmonetized, in the one year when a mandatory specialty model and a mandatory hospital model both land on this market at once. This page sizes that layer as a margin-positive service line, built with the same discipline the group's roughly 4,600 device-monitoring relationships already prove.
Source: the companion CoachCare Value Analysis workbook, MAC locality FL • 09102-99.
This practice does not need convincing that nurse-run, protocol-driven, between-visit care works. Its own Medicare claims show it running that model already — at volume, on the device side. The physiologic side is simply unmonetized.
CPT 93294 · 93295 · 93297 · 93298, billed across seven of the group's core physicians in CY2024 Medicare fee-for-service — including 999 beneficiaries on remote pacemaker interrogation and 1,285 on remote rhythm monitoring.
CPT 93297, across the same seven core physicians. Implantable pulmonary-artery pressure sensors are placed in advanced heart failure. That is an already-identified, already-remotely-managed heart failure cohort — sitting directly on top of the model the practice is mandated into.
Both ran under those exact names on the practice's own website for over a decade. A warfarin clinic is a care-management program: scheduled non-visit touches, protocol-driven titration, nurse documentation. The concept needs no selling.
Every provider reassigning to the group was queried individually against the full CY2024 Medicare care-management code set — remote physiologic monitoring, principal care management and transitional care management included. Zero services, on every code, for every provider. Verified absent, not suppressed.
The hard part of a remote care program is not the technology. It is the operating habit — a triage inbox, an alert-review protocol, a documented escalation standard, and clinicians who trust data arriving between visits. This practice built that habit twenty years ago and still runs it every day. What is missing is the billable layer on top of it.
The zero-billing finding is evidence of absence in CY2024 Medicare fee-for-service specifically. A program launched in 2025 or 2026, or one billed to commercial or Medicare Advantage payers, would not appear in that file.
One reaches the practice's own cardiologists. The other reaches every hospital it admits to. Neither is optional, and a single remote care service line is the operating answer to both.
Three of the group's cardiologists are named on the CMS preliminary CY2027 participant list for the Ambulatory Specialty Model, in the Heart Failure cohort, under the legal entity Okaloosa Cardiology, P.A. — each flagged as a small practice. ASM makes cardiologists individually accountable for heart failure cost and quality, with first-year Part B payment swings of roughly −9% to +9%.
Both hospitals the group admits to are mandatory TEAM participants: CCN 100223 (HCA Florida Fort Walton-Destin) and CCN 100054 (HCA Florida Twin Cities), CBSA 18880, performance period 1 Jan 2026 – 31 Dec 2030, per the CMS TEAM participant list as of 15 Apr 2026. In fact all five hospitals in the CBSA are mandatory participants.
Said plainly: the practice has no CCN and is not itself a TEAM participant — TEAM participation attaches to a hospital CCN. But its admitting partners now carry 30-day post-discharge episode accountability, including readmissions, and the physicians who actually control post-discharge cardiac outcomes sit outside the entity bearing the risk. The group is the lever that moves it.
New codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) make short post-discharge and post-procedure monitoring windows cleanly billable — removing the 16-day floor that previously blocked episodic remote care. That is precisely the window TEAM reconciles on.
A named service line with its own owner, P&L and scorecard — not a point solution bolted onto one condition. It follows the Medicare patient from the hospital bed back into the practice and then across the year: built once, reused for every value lever the group already cares about.
| Service | Codes | ~CY2026 Magnitude | Cardiovascular Use | In the model? |
|---|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every heart failure and post-procedure discharge from the two admitting hospitals | No — upside |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | 99445 opens the 2–15-day post-discharge window | Yes |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$52 + ~$41 add'l | Monthly review, titration, escalation | Yes |
| Principal Care Management | 99424 · 99425 · 99426 · 99427 | ~$60 + ~$50 add'l | Single high-risk cardiac condition (heart failure) expected to last ≥3 months | Yes |
The value analysis below uses CY2026 rates auto-resolved by MAC carrier and locality for zip 32539 — FL • 09102-99 — not the national figures shown above.
The same infrastructure — enrollment, devices, alert triage, escalation, documentation, billing capture — powers each thing the group already cares about.
Every remote care program lives or dies on whether the data lands in the chart the clinicians already use. Here is exactly what is known about this practice's platform, what is inferred, and what the integration looks like under each answer.
The value analysis on this page does not assume any particular integration depth. No interface cost, timeline or capability is priced into the forecast, and none is claimed here.
The economics prove the service line pays. This proves it is safe and disciplined. Every reading a patient takes routes through one shared escalation engine with defined thresholds, defined trends, defined routing and a defined documentation standard — so the practice receives signal, not noise, and never carries surveillance liability it did not agree to.
Both programs in this service line — remote physiologic monitoring and principal care management — route through the same logic. The engine is program-agnostic; the thresholds are set with the practice.
A reading at a critical threshold escalates regardless of whether the patient reports symptoms. There is no "wait and see" branch on a critical value, and no client preference can suppress it.
A non-critical out-of-range reading is worked rather than forwarded: confirm technique, retake, then run a structured symptom check. Most out-of-range readings resolve here — which is exactly why the practice's inbox stays clean.
An out-of-range trend is not a judgement call. It is three consecutive readings at least one hour apart for blood pressure or glucose, or three readings within seven days for heart rate. A confirmed trend escalates on the same footing as a threshold breach.
If the patient cannot be reached, the attempt is documented, a voicemail and callback request are left — and if the reading was critical or a confirmed trend, the escalation proceeds anyway. Silence never downgrades a clinical finding.
Six fields, every time, so the record is auditable and the practice can reconstruct any event.
Triggered automatically by any emergency-room visit or hospitalisation reported in the last 60 days. This is the readmission-prevention spine — and the mechanism behind the 241 hospitalizations avoided in the forecast below. It matters here specifically: Okaloosa County runs a 19.54% acute readmission rate against 18.07% nationally.
Confirm the patient is home and safe, reconcile discharge medications against what is actually in the house, verify follow-up appointments exist, and confirm the monitoring device is set up and transmitting. Clinical alerts documented and escalated per the engine above.
The window where post-discharge decompensation typically declares itself. Symptom review, weight and blood-pressure trend review against the readings already flowing in, adherence check, and escalation on any confirmed threshold or trend.
Confirm the follow-up visit happened, close open issues, verify the patient understands the escalation path, and hand the patient into the longitudinal monitoring panel so the 30-day window closes with continuity rather than a cliff.
Patients do not silently fall out of the programme, and the practice is notified at every decision point.
A patient who stops responding is escalated to the practice first, then re-escalated every 30 days — not quietly dropped and not left accruing.
If no instruction is received from the practice, discharge proceeds at 180 days. The clinic is notified in every case, and discharges generally process in the first week of the following month.
Clinical discharge criteria, escalation thresholds and routing are the practice's to set. CoachCare executes them consistently and documents the execution — it does not overrule clinical judgement, with the single exception of the emergent floor above.
Because every escalation carries the same six documented fields, any episode can be reconstructed end-to-end — which is what a risk-bearing conversation with a hospital partner or a CMS model reviewer actually requires.
A 24-month forecast for a two-programme service line — remote physiologic monitoring and principal care management — across the group's four sites, 19 referring providers, one CoachCare-funded on-site enrolment specialist, and CY2026 rates auto-resolved for MAC locality FL • 09102-99. Transitional care management revenue, TEAM episode performance, ASM payment adjustment, avoided-admission savings and procedural throughput are not in these numbers. They are upside on top.
| Line | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $859,892 | $2,615,394 | $3,475,286 |
| PCM net reimbursement | $292,810 | $917,243 | $1,210,053 |
| Total net reimbursement | $1,152,701 | $3,532,637 | $4,685,339 |
| CoachCare fees | $670,573 | $2,028,705 | $2,699,278 |
| Practice net (after fees) | $482,128 | $1,503,932 | $1,986,060 |
| Practice margin | 41.83% | 42.57% | 42.39% |
| Includes one on-site enrolment specialist staffed at CoachCare's expense — embedded value already reflected in the fees above, never a deduction from practice margin. | |||
Month-1 practice profit is −$2,188; the first profitable month is month 2. The full model is available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months — on top of the existing procedural and imaging book, not instead of it.
A continuous clinical picture of the heart failure, AFib, CAD and hypertension panels between visits — the physiologic twin of the device data the group already reviews.
Roughly $3.6M of avoided acute cost at an assumed $15K per admission — and direct 30-day episode relief for the two mandatory-TEAM hospitals the group admits to.
39,820 care-team hours of monitoring, outreach, escalation and documentation carried by the service line rather than by practice staff.
Every input below is an assumption, and every assumption is arguable. Move them and the 24-month forecast recomputes live. At the modeled settings this engine reproduces the companion Value Analysis workbook exactly — so any disagreement you have with the output is really a disagreement with an input, which is a much more productive conversation.
"Enrolled services" counts active programme enrolments; a patient enrolled in both programmes counts twice. At month 24 the model's 3,901 enrolled services correspond to 3,144 unique patients once dual enrolment is deduplicated.
CoachCare operates the engine — enrolment outreach, device logistics, 24/7 monitoring, escalation and billing-ready documentation — while the group's physicians govern the protocols and make every clinical decision. Full-service delivery means launch requires no new practice headcount, and the on-site enrolment specialist in the model is funded by CoachCare.
Named service-line owner, P&L and scorecard. Confirm the ambulatory EHR and the billing configuration for MAC locality FL • 09102-99. Agree the escalation matrix and discharge criteria.
First, the heart failure cohort already under implantable hemodynamic monitoring — identified, engaged, and the exact population the specialty model measures. Second, post-discharge patients from the two admitting hospitals, on the three-touch cadence with short-window RPM at discharge.
Crestview, Fort Walton Beach, Niceville and Destin enrolling; longitudinal RPM and PCM panels running under protocol; monthly scorecard — census, capture rate, revenue per patient-month, escalation volume, readmission signal — reporting to practice governance.
A full performance record on the heart failure panel ahead of the CY2027 specialty-model performance year, and a documented 30-day post-discharge track record to take into the hospital conversation — which is where the episode-risk discussion becomes a negotiation rather than a request.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for more than 500,000 patients.
Providers running remote care programmes day to day.
Successful programme implementations.
Care plan coding and billing generating over five million claims.
Over 100 million vitals recorded and more than four million care actions enabled.
CMS's CY2027 Physician Fee Schedule proposed rule, published July 16, 2026, proposes to reprice remote physiologic monitoring. Here is what it reaches, what it leaves alone, and how the operating model behind this service line absorbs it.
CMS's remote-monitoring proposals sit in one code family: RPM. CCM, PCM, and TCM are not part of them. That distinction lands directly on this forecast — PCM carries $1,210,053 of the modeled $4,685,339 in 24-month net reimbursement, and the TCM touch at discharge is outside the proposal entirely. Neither is in scope.
The delivery model has more than one shape, and CoachCare is preparing each so the service line's economics hold wherever the rule settles. One unbundles the program into its parts — SaaS platform, device logistics, and program enablement — priced as components. Another engages CoachCare to run the staffing itself, an MSO-style arrangement in which the practice owns the clinical program and the billing while CoachCare carries the labor model. Neither requires re-architecting the service line described on this page.
Alongside the fee schedule, CMS's ACCESS Model pays remote care as a risk-based per-member-per-month arrangement rather than per code: recurring per-beneficiary payments, half of each one withheld and reconciled against outcome attainment. Cardiometabolic care is among its four clinical tracks. What earns under that structure — controlled pressures, titrated therapy, decompensations caught early — is what this service line is built to produce.
This forecast repriced code by code at CMS's CY2027 proposed values, at this practice's own MAC locality rather than national averages. Same enrollment, same phasing plan — only the rates move.
Both bars run on the same dollar scale, so the red slice is nearly the same width in each — the same dollars, measured against a larger base. The empty track on the top bar is the care-management revenue RPM alone does not include.
Repriced at this locality's own geographic adjusters. The RPM reductions fall almost entirely on practice expense, so the untouched work component carries more weight in some localities than others; the same repricing at national rates would be −8.8% on RPM. Of the $297,115, RPM accounts for $290,702 and the care-management arm for $6,413.
CY2026 versus CMS's published CY2027 proposed values, shown at national non-facility amounts so they can be read against CMS's own tables. This practice's locality-adjusted amounts differ; the repricing above uses the local figures.
| Code family | What CMS proposed | CY2026 | CY2027 proposed | Change |
|---|---|---|---|---|
| In scope — remote physiologic monitoring | ||||
| 99454 / 99445 · device supply | Practice expense recrosswalked | $52.11 | $41.38 | −21% |
| 99457 · management, first 20 min | Direct practice expense removed | $51.77 | $49.59 | −4% |
| 99458 · management, each addl 20 min | Direct practice expense removed | $41.42 | $40.39 | −2% |
| 99453 · setup and patient education | Crosswalked; one-time per patient | $21.71 | $20.03 | −8% |
| Not in scope — the codes the proposal does not reach | ||||
| 99424–99427 · PCM | No structural change proposed | $67.80 | $67.00 | −1% |
| 99495 / 99496 · TCM | Not addressed by the proposal | Outside the remote-monitoring provisions entirely | ||
National non-facility amounts; CY2027 values are CMS's own published proposals in Addendum B of CMS-1848-P. The care-management rows show the lead code in each family; every code in those families moves within about 4% in either direction, which is ordinary annual movement rather than a repricing. The RPM reductions are also phased — section 1848(c)(7) of the Act caps any one code's total-RVU reduction at 19% in a single year, and CMS publishes the affected codes, so CY2027 is a single-digit year for a typical program and the remainder arrives no earlier than CY2028.