The primary care panel in Fountain Hills and Gilbert already carries the conditions Medicare pays to manage between visits: hypertension, type 2 diabetes and high cholesterol. This is the 24-month plan to bill for that work on Azalea, with CoachCare staffing the program, to add transitional care at every hospital discharge the ER sees coming, and to carry the same model into every clinic the group adds.
Two counts, two jobs. The headline is 413 unique patients at month 24; the enrollment chart and the Scenario Explorer show 634 active program enrollments, because a patient on both RPM and CCM is one patient and two enrollments.
A physician-owned emergency room with a primary care and urgent care clinic beside it, a second clinic in Gilbert, a Medicare panel that skews toward the conditions remote care manages best, an accountable-care contract that rewards keeping those patients out of the hospital, and a new EMR that CoachCare already integrates with. What is missing is the service line itself.
The practice's billing entity appears on the CMS PY2026 Shared Savings Program participant file inside an Enhanced-track ACO, the track with two-sided risk, where avoided admissions among its own patients turn into shared savings.
CY2024 Medicare claims for the two highest-volume internists at 9700 N. Saguaro show hypertension in 73–74% of beneficiaries, diabetes in about one in five, and chronic kidney disease in 16–24%. Most of the panel is 75 or older.
Board-certified emergency physicians, on-site CT, X-ray, ultrasound, lab and pharmacy. Every ER visit by a panel patient is a signal the care team can act on the same week, not a chart note discovered at the next annual visit.
The group is moving to Azalea Health today. CoachCare is an Azalea integration partner with a bi-directional connection, so the remote care program can go live inside the same implementation window instead of after it.
One structural fact completes the picture: at Fountain Hills, no remote patient monitoring, chronic care management or advanced primary care management program is visible at meaningful scale in CY2024 Medicare claims or public materials. The Gilbert clinic ran a small physician-led RPM and CCM program in 2024, which is proof the panel responds; the practice-wide, staffed service line is what does not exist yet.
Three things line up for an independent primary care group in the Valley in 2026: richer remote care billing, a two-sided ACO contract that pays for the same outcomes, and a growth plan that needs a program built once and installed many times.
New CPT codes 99445 (2–15 days of device data) and 99470 (the first 10 minutes of management) remove the 16-day floor that used to block episodic monitoring. Post-discharge and titration windows are now cleanly billable next to the standard monthly RPM stack, and TCM at the discharge itself pays for the hand-off.
Under the Enhanced track the ACO shares in savings and losses. The between-visit touches that generate care-management revenue are the same touches that keep hypertensive and diabetic patients out of the hospital, which is where shared savings come from.
The group plans two more clinics next year and a Valley-wide network of 25 to 30 clinics inside five years, including cardiology. A remote care program that runs at a 40%-plus operating margin is a plug-in for every clinic acquired, live from the first month a new panel comes on.
A named service line with its own P&L and scorecard, following the multi-chronic Medicare patient the practice already knows, inside the Azalea chart the practice is moving to now.
| Service | Codes | CY2026, Arizona locality | Use across the panel |
|---|---|---|---|
| Chronic care management | 99490 · 99439 | $64.85 + $49.41 add'l | The longitudinal wrapper; two or more chronic conditions |
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $20.96 setup · $50.45/mo | Hypertension, diabetes and heart-failure cohorts; 99445 opens 2–15-day windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $50.65 + $40.61 add'l · $25.49 | Monthly review, titration, escalation |
| Transitional care management | 99495 · 99496 | $215.45 / $292.37 per discharge | Every hospital or observation discharge the ER transferred or learns of; not in the forecast below |
| Advanced primary care management | G0556 · G0557 · G0558 | $16.04 · $52.72 · $114.88/mo | Named as the next lever; not in any figure on this page |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 85268 (Noridian, Arizona locality 00), the same basis the Value Analysis below is priced on.
The group is implementing Azalea Health now. CoachCare is an Azalea integration partner: eligibility flags and orders leave the chart, monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The integration typically takes about four weeks, so it fits inside the implementation already under way.
typical Azalea integration timeline, run in parallel with onboarding, training and care-team assignment.
a physician or APP flags an eligible patient and submits the referral from inside Azalea; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the practice's own billing team already runs. No PDFs, no re-keying.
Same panel, same Arizona rates, same 24 months. The full-service column is the forecast on this page. The software-only column runs the same enrollment engine with two things an in-house team carries: enrollment at three-quarters of the pace, because nobody's whole job is enrolling, and code completion 25% lower, because time-based codes only pay when the minutes are logged every month. CoachCare's platform and device fees are at list; the practice hires the clinical minutes.
CoachCare staffs enrollment outreach, monitoring, care management and billing preparation
The practice employs the care team and runs enrollment; CoachCare supplies the platform, Azalea integration and devices
The group's plan is more clinics, fast. This runs both models through that plan: the two clinics today, then one new location every quarter from month 4, each bringing 500 in-scope Medicare patients and three referring clinicians. Move the slider to match the plan you are actually working. Full service adds care team as the census grows, so every new site inherits a running program the month it opens. Software only carries what an in-house program carries at scale: each new site waits three months for a trained lead before enrolling, the team hires one care manager at a time and each hire lands three months after the requisition, one in four care managers turns over every year, and the pace and completion handicaps above apply everywhere.
The Value Analysis shows the program pays. This is how it stays safe. Every blood pressure, weight or glucose reading and every CCM check-in routes through the same protocol, so the practice sees signal rather than noise, and a physician-owned group keeps clinical control.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling. CoachCare's urgent and emergent policy supersedes any client-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 or nurse the practice designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a symptom check that is clean closes the loop with a chart note and nothing else. The practice's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule, the practice is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
Any emergency room visit or hospitalization in the last 60 days triggers three touches inside two weeks. For a practice with its own 24/7 emergency room, that trigger fires the same day, and when the patient was admitted it is also the TCM episode: contact within two business days, the visit within 7 or 14 days. That cadence is where the modeled 44 avoided hospitalizations over 24 months come from.
Reach the patient, reconcile medications against the discharge instructions, confirm the device is transmitting.
Symptom and reading review, barriers to the plan, follow-up appointment confirmed with the practice.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + CCM stack: a 1,750-patient Medicare panel across the Fountain Hills and Gilbert clinics with 1,400 in scope for Year 1, 7 referring clinicians plus CoachCare's enrollment outreach, Arizona locality rates for ZIP 85268, and the Azalea integration. Shared-savings upside and APCM are not in these numbers.
| Program | Net reimbursement | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM: devices, data and management | $623,799 | $367,692 | $256,107 |
| CCM: chronic care management | $693,609 | $360,636 | $332,973 |
| Implementation, Azalea integration and outreach | — | $28,009 | −$28,009 |
| 24-month total | $1,317,408 | $756,337 | $561,071 |
| 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: 42.6% of net reimbursement (Year 1 41.8%, Year 2 43.1%).
Year 1 is $228,950 net to the practice on $547,561 of net reimbursement; Year 2 is $332,121 on $769,847. Month 1 is −$1,985 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 inside Azalea.
Blood pressure and weight, a continuous picture of the hypertension and diabetes cohorts between visits.
About $657K in acute-care cost that never gets spent, at $15,000 per admission. Under the Enhanced track, that is shared-savings arithmetic.
About 11,308 care-team hours of monitoring, outreach and documentation carried by the service line, not by practice staff.
RPM reaches its ceiling of 319 enrollments in month 7 and CCM its ceiling of 315 in month 8. From there the census holds at 634 active enrollments, 413 unique patients. The binding constraint on this forecast is the size of the in-scope panel, not outreach capacity. That is exactly the constraint a group adding clinics is about to relax.
| Program | Enrollment ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 319 | 1,400 in scope × 65% eligible × 35% acceptance | Month 7 |
| CCM | 315 | 1,400 in scope × 75% eligible × 30% acceptance | Month 8 |
| At month 24 | 634 | Active program enrollments = 413 unique patients | — |
Eligibility is set for an adult primary care Medicare panel. Every point of eligibility or acceptance the practice's own chart data supports beyond these raises the ceiling, and the forecast, directly.
Instinctive Healthcare Solutions already runs two freestanding emergency rooms and two clinics, with a Central Phoenix hospital and ER and a South Tempe pair on the way. Each clinic the network opens or acquires brings a new Medicare panel with the same condition mix. Because the service line runs at a 42.6% margin and CoachCare carries the staffing, a new site inherits the program in its first month rather than rebuilding it. The Scenario Explorer above is the sizing tool for each one: put in the panel, read off the forecast.
Advanced Primary Care Management (G0556–G0558) is Medicare's bundled monthly payment for the panel this program manages, and its value-model requirement is one the practice already meets through its Shared Savings participation. It carries zero dollars on this page. Once real enrollment data exists, the CCM-versus-APCM mix is the first design decision to make together.
CoachCare operates as the service line's engine while the practice's physicians govern protocols and every clinical decision. Full-service delivery means launch needs no new practice headcount; the Azalea integration runs in parallel with onboarding, and the first enrollments follow the first referral orders.
Azalea integration built alongside the practice's own implementation; named program lead at the practice; P&L and scorecard; billing configuration with the in-house team; protocol sign-off for the hypertension, diabetes and lipid pathways.
CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts; CoachCare's enrollment outreach working both clinics; TCM and the ER-visit follow-up cadence live from day one.
RPM reaches its modeled ceiling in month 7 and CCM in month 8; monthly scorecard to the executive team; Gilbert panel worked in parallel.
Re-validate eligibility against chart data, decide the CCM-versus-APCM mix, align reporting with the ACO's quality and cost measures, and install the program at each new clinic as it opens.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline. Here is what they do to the forecast on this page, priced at the practice's own Arizona locality amounts rather than national averages.
The proposals reach the remote-monitoring family only. Chronic care management is not in them, and on this forecast CCM carries $693,609 of the $1,317,408 in 24-month net reimbursement. Its own amounts move by about two points, so $14,641 of the $73,949 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 MSO-style 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. For a group that already asked to see the software-only case, that second shape is the one to watch.
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. Fee-for-service code cuts and that shift are the same policy argument. Pay for results rather than for device-months.
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 locality 00 amounts, non-facility, on this practice'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 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: care management | ||||
| 99490 | Chronic care management, first 20 minutes | $66.13 | $64.04 | −3.2% |
| 99439 | Chronic care management, each additional 20 minutes | $50.44 | $49.92 | −1.0% |
| G0556 | Advanced primary care management, level 1 | $16.37 | $16.09 | −1.7% |
| G0557 | Advanced primary care management, level 2 | $53.78 | $53.20 | −1.1% |
| G0558 | Advanced primary care management, level 3 | $117.24 | $116.91 | −0.3% |
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.
Comments on CMS-1848-P are due 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.