A 5,000-patient heart-failure cohort, instrumented. Not the whole panel — because on hypertension and diabetes alone the arithmetic does not work, and under a full-risk contract every avoidable charge lands on your loss ratio. Heart failure is where the $15,000 admissions are, and it is where continuous weight and blood-pressure monitoring catches decompensation early enough to prevent one.
Two numbers, two different jobs. $3.15M is avoided cost — the number that matters against a full-risk contract. $2.43M is retained fee margin — the number that pays for the program while the risk-side benefit accrues. The headline counts 1,958 deduped unique patients; the enrollment chart and calculator show 2,850 active program enrollments (services), because a patient on both RPM and CCM is one patient but two enrollments.
SOFHA runs a centralized chronic care management team — five nurses covering every clinic in the market, at roughly 330 patients a month. That is a real, working program, and it is the hardest part of this to build. It is also where in-house programs typically stop: staffing scales linearly, and the wall usually arrives somewhere between two and three hundred patients.
Five nurses running Medicare Chronic Care Management across every clinic, billed monthly. The clinical judgment, the protocols and the patient relationships already exist — nothing in this proposal replaces them.
A trained nurse rechecks the reading and coaches home measurement technique. There is no connected cuff, no transmitted reading, no dashboard — and therefore no 99453, no 99454, no 99457, and no early-warning signal between visits.
No RPM program runs today. The diabetes side offers professional CGM — a three-day, retrospective, referral-only study alongside an ADA-recognized education program. Excellent clinically; not continuous, and not a recurring monitored program.
The configuration modeled here reaches 1,275 CCM enrollments — about four times current monthly volume — plus 1,575 on RPM. Reaching that in-house is a hiring plan. This proposal reaches it without one.
SOFHA is not a fee-for-service practice deciding whether to try value-based care. It is already inside it — ACO REACH on the traditional Medicare book, risk arrangements on the Medicare Advantage book, and full-risk capitated Medicare contracts. That changes what this program has to prove. It is not enough for it to bill; it has to take cost out faster than it adds it.
On the modeled cohort, ~210 avoided admissions ≈ $3.15M against $2.43M of retained fee margin. The avoided-cost line is the larger of the two. That is the whole argument for putting this on heart failure rather than the panel.
Open the referral flag to every provider and every patient and the charges land on your loss ratio without the matching savings. Enrollment is restricted to an agreed cohort you approve — a flag on a patient outside it does not enrol them. That control is a design requirement here, not an afterthought.
Whatever comes next — a return to the Shared Savings Program, or a later LEAD cohort — will still be judged on total cost of care. The capability below is what performs against that, and it takes twelve to eighteen months to reach steady state.
On the policy horizon: ACO REACH sunsets 31 December 2026, and CMS's successor, the LEAD model (Long-term Enhanced ACO Design), runs 1 January 2027 through 2036 with Professional Risk up to 50% and Global Risk up to 100%. LEAD was written with enhanced support for small, independent and rural primary-care practices and an enhanced focus on rural, high-needs and dual-eligible populations. Its first-year application window closed 17 May 2026 and later cohorts have not been published, so the near-term routes are a return to MSSP or a later LEAD cohort. Which door you take is your modelling exercise, not ours. The point is that every door has the same operating requirement — a consented longitudinal panel, documented monthly care management, continuous physiologic data, and a readmission loop that actually closes.
The instinct with these programs is to size them against the whole eligible panel. Under full risk that instinct is expensive. A patient with well-controlled hypertension who has been steady on their medications for three years generates a monthly charge and produces no avoided admission. Scale that across a panel and you have moved cost onto your own loss ratio.
The heart-failure cohort, selected from the record by diagnosis. Start here, prove the unit economics on the population where savings are most likely, then decide about widening on evidence rather than on hope.
RPM 90%, CCM 85% of the cohort. Weight-plus-blood-pressure monitoring is the canonical heart-failure protocol, and Medicare heart-failure patients carry several chronic conditions on average, so nearly all qualify for CCM.
Over 24 months, ≈ $3.15M at ~$15,000 each. Identical in both configurations below — avoided admissions are driven by RPM patient-months, so adding CCM raises revenue without changing the clinical outcome.
SOFHA has already proven it can run this clinically with five nurses. What this section answers is what it costs to run it at cohort scale — 1,575 monitored patients and 1,275 on CCM — and where the money goes in each case. This is arithmetic about scaling, not a comment on the quality of what exists.
Two codes new for CY2026 matter disproportionately for a heart-failure cohort, because heart-failure patients are exactly the ones who miss the old thresholds.
| Service | Codes | Use in a Heart-Failure Cohort |
|---|---|---|
| RPM setup & device supply | 99453 · 99454 · 99445 (new 2026) | 99445 bills a 2–15 day window instead of requiring 16 days — the post-discharge period, the titration window, and the patient who transmits inconsistently |
| RPM treatment management | 99457 · 99458 · 99470 (new 2026) | 99470 bills 10–19 minutes, below 99457's 20-minute floor — the stable month that used to go uncompensated |
| Chronic Care Management | 99490 · 99439 | Heart failure rarely travels alone; nearly all of this cohort carries two or more chronic conditions |
| Transitional Care Management | 99495 · 99496 | Billable at discharge — excluded from the model, upside on top |
| Excluded from every modeled figure on this page | ||
| Principal Care Management | 99426 · 99427 | Off — heart failure is the dominant condition and CCM carries it; PCM and CCM cannot both bill in one month |
| Advanced Primary Care Management | G0556 · G0557 · G0558 | Off — a fee-schedule service in Original Medicare, named as a build-toward target only |
Rates auto-resolve to SOFHA's Tennessee MAC locality (Palmetto GBA, carrier 10312, locality 35) from the CY2026 Physician Fee Schedule — local rates, not national averages. Blended net reimbursement per active patient-month, after denials and coinsurance bad debt, is modeled at ~$90.32 RPM and ~$104.15 CCM. Patient responsibility on Medicare runs roughly $20–$40 per month for the combined services; enrollment friction rises above about $40, and qualified Medicare beneficiaries cannot be balance-billed at all.
The most dangerous thirty days in a heart-failure patient's year begin the moment they leave the hospital. Almost every independent group loses visibility across that gap, because someone else's hospitalist discharges their patient. SOFHA does not have that problem — and its care managers are already booking the post-discharge appointment inside the three-to-five-day window.
SOFHA's own directory assigns 68 clinicians to its hospital-based division. They manage SOFHA patients during admission and hand them back to a SOFHA physician.
49 family medicine and 24 internal medicine providers receive those patients into a continuity relationship — the referring base modeled here.
The centralized nursing team that already runs the transition — medication reconciliation, the follow-up appointment, readmission prevention — inside the same organization.
Two questions decide this for a physician-led group: what happens when a reading goes wrong, and who is the patient hearing from. Both are answered by documented protocol — CoachCare's Care Management Standard Operating Procedures — reviewed and customized with your physician leadership during implementation, not handed to you finished.
Enrollment is limited to the list you approve. If a provider flips the referral flag on a patient outside the agreed cohort, our team can see that the patient is not in scope — the flag does not auto-enrol anyone. That is the direct answer to keeping charges off the loss ratio.
Thresholds, care pathways and messaging are set in a dedicated implementation session with CoachCare's chief medical officer and your leadership. Guideline-based to start — heart-failure weight fluctuation, blood-pressure thresholds — then tuned. If escalations are too noisy, the thresholds move.
The care team is a nursing layer, not a parallel practice. Every escalation, medication question and follow-up routes back into SOFHA — appointments scheduled with your physicians, med-rec notes sent to the prescriber. The patient relationship stays yours.
Every RPM and CCM reading runs the same decision logic, so escalations are consistent rather than subjective — and a critical value escalates regardless of symptoms.
A vital arrives from the patient's cellular device — weight, blood pressure, or pulse oximetry — into the monitoring queue.
A critical value escalates regardless of symptoms. An out-of-range value first gets a retake plus a symptom check before anything reaches the practice.
A trend is defined objectively — 3 consecutive out-of-range readings ≥1 hour apart for blood pressure, or 3 within 7 days for heart rate — never a single stray number.
If the patient cannot be reached, the team leaves a voicemail with a callback line and still escalates a critical value or trend. Every escalation documents vital, findings, method, contact, outcome and follow-up.
Any of these, reported live during outreach, moves straight to the emergency pathway:
Several of these are decompensation presenting in person. On a heart-failure panel this is the pathway that matters most.
Any ER visit or hospitalization in the last 60 days triggers a fixed three-touch sequence — the concrete loop behind the ~210 avoided admissions on this page. Each touch documents and escalates per protocol.
Identify precipitating factors, reconcile medications, confirm follow-up in 7–14 days, assess symptoms.
Verify medication adherence, re-evaluate triggers, confirm the appointment happened, verify labs.
Review medications and risk, review the outcomes of the completed visit, re-assess symptoms.
CoachCare uses built-in Veradigm workflows, so SOFHA's clinicians enroll and monitor patients without learning a new system. A physician seeing a heart-failure patient flips a flag in Veradigm; that flag reaches our team, who call the patient, answer questions, obtain consent and ship the device. Vitals, documentation and claims flow back.
Remote vitals file beneath the office-based vitals rather than mixing with them — so thousands of home blood-pressure readings do not dilute the office data you use to finalize controlled-blood-pressure quality reporting.
Flag flipped in Veradigm, patient called, consented and shipped a device on the same call, with delivery tracked and a follow-up call to confirm the first reading. Patients begin receiving services in under five days.
CoachCare is the only care management application integrated with Veradigm Practice Management that provides automated claims creation — eliminating the manual claim step for each patient, every month.
A 24-month forecast on 5,000 heart-failure patients in scope, 73 referring adult primary care providers, one CoachCare-funded on-site enrollment specialist, telephonic enrollment, Tennessee MAC-locality CY2026 rates and native Veradigm integration. Two configurations, because you asked for both. Transitional Care Management is billable at discharge and is not in these numbers.
| 24-month outcome | RPM only | RPM + CCM |
|---|---|---|
| Net reimbursement | $2,843,849 | $5,453,555 |
| Total fees (no one-time charges) | $1,680,031 | $3,027,687 |
| Net to the practice | $1,163,818 | $2,425,867 |
| Practice margin | 40.9% | 44.5% |
| Active program enrollments, M24 | 1,575 | 2,850 |
| Unique patients, M24 | 1,575 | 1,958 |
| Hospitalizations avoided · avoided cost | ~210 · $3.15M | ~210 · $3.15M |
| First month net to practice | +$4,350 | +$7,335 |
| Program | Net reimbursement | Total fees | Net to practice |
|---|---|---|---|
| RPM — devices, weights & management | $2,843,849 | $1,680,031 | $1,163,818 |
| CCM — chronic care management | $2,609,706 | $1,347,657 | $1,262,049 |
| Implementation, Veradigm integration & telephonic outreach — included at no cost | — | $0 | $0 |
| 24-month total | $5,453,555 | $3,027,687 | $2,425,867 |
| Delivered full-service — telephonic enrollment, the on-site enrollment specialist, devices and monitoring are staffed at CoachCare's expense. No capital outlay and no new practice headcount to launch, and none of that staffing is deducted from the net above. | |||
Year 1 is $973,446 net to the practice on $2,169,757 of net reimbursement (44.9%); Year 2 is $1,452,422 on $3,283,797 (44.2%). Because the cohort fills inside year one, Year 2 is a full year at steady state rather than a growth year.
Full model available as a companion workbook.
Set CCM conversion to 0% to see the RPM-only configuration.
≈ $3.15M in avoided acute cost at ~$15,000 per admission — the line that matters against a full-risk contract.
Daily weights and blood pressures on a heart-failure panel — the earliest available signal of decompensation.
Recurring professional-fee volume over 24 months across RPM and CCM.
≈ 23.3 FTE-equivalent of monitoring, outreach and documentation carried by the service line rather than by your five nurses.
CoachCare runs the engine: enrollment outreach, device logistics, reading triage and billing-ready documentation. SOFHA's physicians govern protocols and every clinical decision. Launch requires no capital and no new headcount, and your five nurses keep the relationships they already own.
Named owner, P&L and scorecard; Veradigm integration and billing configuration; agree the cohort definition and the approved enrollment list; clinical SOP session with your physician leadership to set thresholds, care pathways and scripting.
Enroll heart-failure patients with a recent admission first, layering RPM onto the CCM relationships your nurses already hold. Add TCM capture on discharges from the hospital-based division. ~690 active enrollments by day 90.
Extend across the full 5,000-patient heart-failure population; RPM reaches its ceiling around month 8 and CCM around month 9; monthly scorecard reporting on census, capture, escalation rate and admissions.
Read the admission data against your own risk contracts. If the avoided-cost thesis holds on heart failure, extend to CKD stage 2–3 and COPD — on evidence, not on hope — and take the documented outcomes into the LEAD-versus-MSSP decision and your MA plan conversations.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 conditions managed for 500,000+ patients.
Providers running remote care programs day to day.
Remote care programs launched on this infrastructure.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions delivered.
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 — CCM carries $2,609,706 of the modeled $5,453,554 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 $306,481, RPM accounts for $251,412 and the care-management arm for $55,069.
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 | ||||
| 99490 / 99439 / 99491 · CCM | No structural change proposed | $66.13 | $64.04 | −3% |
| 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.
Six reasons this partnership fits State of Franklin Healthcare Associates specifically, not remote care in general.
CoachCare integrates bi-directionally with Veradigm: eligibility flags and orders leave the EHR, and discrete vitals, care documentation and claim-ready charges come back into it. One chart across the primary-care and cardiology clinicians, one workflow for the billing team, and no second system to learn to start.
Enrollment outreach, the care team, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The group inherits a running program the month it turns on, at a 44.5% margin, with no hiring cycle. On-site enrollment is our expense, because telephonic outreach converts about 8%, so we staff the clinic instead.
Your physicians set the protocols, sign the care plans and make every clinical decision, and claims go out under the group's own entity and the NPIs the clinicians already bill through. CoachCare supplies the staff, devices, platform and billing preparation under that governance.
Most groups lose the transitional care window because someone else's hospitalist discharges their patient. State of Franklin does not have that problem. The group discharges its own heart-failure patients, so the post-discharge period becomes a TCM and RPM enrollment moment inside one care-management spine rather than a handoff that leaks.
The group already carries two-sided risk, and ACO REACH sunsets at the end of 2026 with a return to MSSP or a later LEAD cohort as the near-term routes. A remote care service line is the connective tissue under each of them: broad, documented chronic-care enrollment that holds its value whichever model the group renews into.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. Because the forecast is set by enrollment pace, throughput is the lever. If the census does not build, CoachCare does not get paid, and the forecast, Disclosures and workbook behind this page are yours to keep either way.