MDPCP-AHEAD pays you for the panel you already manage. It does not pay for remote physiologic monitoring — that bills separately under the fee schedule, and it scales with the size of the panel rather than with headcount. You kept those program payments instead of splitting them with a Care Transformation Organization, which means you also carry what a CTO would absorb: monitoring labor, device logistics, documented escalation, automated claims. CoachCare supplies exactly that layer, takes no share of your program payments, and is funded out of the monitoring reimbursement it generates.
Twenty-four-month projection for a remote monitoring program on a 2,500-patient high-risk cohort — the recommended Year-1 scope, not the full panel. Avoided admissions shown at the model's conservative 20% baseline; the realistic figure for this cohort is roughly double. Avoided-cost figures are clinical and system value; they are not added to the practice margin.
Most practices we model have to be convinced that longitudinal care management is worth doing. You have been doing it, under a CMS advanced primary care model, without an institution's infrastructure behind you. Everything below is verified against a primary source.
Maryland's 2026 participating-practice list carries Annapolis Internal Medicine at 116 Defense Highway, Suite 400, with the CTO field reading “No CTO Partner.” Practices that do partner with one split their program payments with it. You kept yours. (MDH, participation as of 1 Jan 2026)
Annapolis Internal Medicine, LLC is a participant in an Enhanced-track Medicare Shared Savings Program ACO — the highest-risk track, shared savings and shared losses — in a physician-led, low-revenue ACO, since January 2025. (CMS PY2026 Shared Savings Program participant file)
Maryland's own program materials feature an AIM physician and an AIM care manager presenting to the MDPCP community. The clinical model here is five years of practice, not a hypothesis. (MDH CTO materials, 2021)
Eight internal medicine physicians and fourteen advanced practice providers — including gerontology and certified diabetes education capability — on a single campus, with a ninth physician joining September 2026. Physician tenure runs from 1991 to the present. One location, one workflow to configure.
Anne Arundel County holds 111,257 Medicare-eligible residents. Original Medicare enrollment rose 3.1% year over year while Medicare Advantage fell 1.4% — the fee-for-service population these codes bill on, and that the ACO attributes, is expanding. (CMS enrollment, Apr 2025–Apr 2026; penetration 19.8%, Jul 2026)
CoachCare's athenahealth integration is bi-directional and is the only care-management integration that generates claims automatically. With no CTO supplying billing support, that is the difference between a program that runs and one that stalls on paperwork.
Two things changed this year, and both cut the same way: Maryland's advanced primary care program was extended rather than retired, and the fee schedule finally pays for the partial months that make up most of real-world monitoring.
On 1 January 2026 the program was folded into the AHEAD Model as MDPCP-AHEAD, continuing through 2028, with AHEAD itself running to 2035. Roughly 460 practices and ~350,000 attributed Medicare beneficiaries statewide. The runway is a decade, not a year.
99445 and 99470 pay for 2–15 days of device data and 10–19 minutes of management. A patient who transmitted twelve days used to be unbillable. Now the partial month counts — and partial months are most months.
In the forecast on this page those two codes alone carry $288,710 of net reimbursement — 17.5% of the total. Two years ago that revenue did not exist.
The Preserve Telehealth Access Act of 2025, effective June 2025, removed time restrictions on telehealth reimbursement across Medicaid and commercial insurance. The delivery model underneath remote care is no longer waiver-dependent in this state.
And your Original Medicare population is growing — up 3.1% in the county last year while Medicare Advantage fell 1.4%.
You carry two-sided risk. New Part B claims for attributed beneficiaries raise your measured total cost of care, so a gross-revenue pitch is worth less to you than it looks. Here is the arithmetic — and the reason we are proposing a monitoring-led program rather than the larger number we could have shown you.
| 24-month — recommended cohort | At 20% admission baseline | At 40% baseline |
|---|---|---|
| Part B claims added | +$1,646,725 | +$1,646,725 |
| Part A avoided (106 vs 213 admissions at $15,000) | −$1,595,585 | −$3,191,170 |
| Net change in total cost of care | +$51,140 essentially neutral | −$1,544,445 strongly favorable |
| Fee margin retained by the practice | +$702,033 | +$702,033 |
Enrolling your whole panel would generate a larger headline and a worse outcome. Monitoring a stable, well-controlled hypertensive produces a monthly charge against your benchmark and very little avoided utilization. Enrolling the cohort where admissions actually happen produces most of the clinical benefit for a fraction of the claims exposure.
That is the recommendation: heart failure, CKD stage 3b–4, COPD, and poorly controlled hypertension and type 2 diabetes first. Roughly 2,500 patients — about half the Medicare panel. Expand only where the data earns it. The panel-wide figure appears later on this page as a ceiling, so you can see it — not as a plan.
The avoided-admission engine assumes a generic 20% annual admission rate — a whole-population figure. A genuine heart-failure and advanced-CKD cohort runs well above that, so the model penalizes the very targeting it should reward:
| Baseline admission rate | Avoided | Avoided cost |
|---|---|---|
| 20% — model default | 106 | $1,595,585 |
| 30% | 160 | $2,393,378 |
| 40% — realistic for this cohort | 213 | $3,191,170 |
| 50% | 266 | $3,988,963 |
Even at the conservative 20% baseline the added claims are almost exactly offset. At a realistic 40% the program is net favorable to your benchmark by roughly $1.5M before a dollar of margin is counted. Your county's Medicare readmission rate is 19.9% and its emergency-department rate 483.5 per 1,000 beneficiaries, so there is real utilization to move. (CMS Geographic Variation, CY2024)
The restriction applies only to attributed beneficiaries. Attribution follows plurality of primary care, so you carry a Medicare population outside it for whom chronic care management is billable. Sizing that group is a discovery question, and we have put no number on it.
Chronic care management remains billable to Medicare Advantage plans and commercial payers even for attributed patients. Roughly a fifth of your county's Medicare population sits in Advantage plans.
PCM is not named in the restriction, but it sits in the same care-management family and may be treated the same way. We have excluded it rather than assume in our own favor.
A Care Transformation Organization hires and manages an interdisciplinary care management team on a practice's behalf, and takes a share of that practice's program payments for doing it. CoachCare supplies the operational equivalent for a chronic-care program — and is paid from the reimbursement it generates instead.
Priced at your own Maryland locality (Novitas JL, carrier 12302, locality 01) — not national averages.
| Program | Codes | What it pays for | MD rate |
|---|---|---|---|
| RPM — device monitoring | 99453 · 99454 · 99457 · 99458 | Setup, monthly device supply with 16+ days of data, and 20-minute management increments | $23.41 · $55.96 · $54.61 · $43.50 |
| RPM — short window 2026 | 99445 · 99470 | 2–15 days of device data; 10–19 minutes of management | $55.96 · $27.47 |
| CCM — chronic care management | 99490 · 99439 | Not billable on your attributed panel — the care management fee replaces it. Retained for non-attributed, Advantage and commercial patients | excluded |
| PCM — principal care management | 99426 · 99427 | Not named in the restriction but in the same family — excluded pending confirmation | excluded |
| TCM — transitional care | 99495 · 99496 | Post-discharge management within 7 or 14 days — the readmission window | not modeled |
For a practice carrying two-sided risk, avoided utilization is the first layer and fee margin is what pays for getting it. We have ordered these accordingly.
Every reading in every program routes through one escalation engine with defined thresholds, defined actions, and defined documentation. Your physicians see signal, not noise — and the billed time is defensible on audit.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache or sudden swelling reported during outreach triggers a 911 call while the patient is still on the line. If the patient refuses, they are routed to the clinic; if they cannot be safely directed, CoachCare activates 911. This policy supersedes any practice-specific escalation preference.
Actionable but non-emergent findings route to a specific, pre-agreed member of your care team — not a general inbox. You decide who, and for which thresholds, during configuration.
Readings worked to resolution are documented as an FYI in the chart with no interruption to your day. This is the route that keeps the other two credible.
RPM, CCM and PCM all route through the same logic. The rules do not change by program — only the codes do.
Any emergency-department visit or hospitalization in the preceding 60 days triggers a fixed three-touch sequence. This is the mechanism behind the avoided-admission figures, and it maps directly onto readmission performance in both your shared-savings program and the state model.
Medication reconciliation against the discharge summary, red-flag symptom review, and confirmation that follow-up is actually booked.
Adherence and tolerance check, device data reviewed against the pre-admission baseline, escalation if the trajectory is wrong.
Stability confirmation and hand-back into the routine monitoring cadence — the window where most preventable readmissions occur.
Your staff do not learn a second system. Enrollment flags, vitals, documentation and claims live inside athenaOne — and CoachCare is the only care-management partner that generates athenahealth claims automatically.
Qualified Medicare patients are enrolled by CoachCare's team, prompted by enrollment flags in your existing workflow. Enrollment status is visible in real time, and patients begin receiving services in under five days.
The billing engine creates claims automatically, eliminating the manual per-patient, per-month step. For a practice with no CTO supplying billing support, this is the operational difference that decides whether a program survives its first year.
Clinical escalations arrive as tasks in the system your physicians already work in, routed to the person you designate — not as email, not as a separate portal login.
athenahealth integration setup and per-patient integration fees are included in the Value Analysis at catalog rates; exact figures are confirmed in contracting.
The charts below model remote monitoring on the recommended 2,500-patient high-risk cohort at Maryland locality rates, with one CoachCare-funded on-site enrollment specialist.
A single-program build, so unique patients and active enrollments are the same number — no dedup is needed: 744 patients at month 24, reached by month 6 and flat from there.
Net reimbursement, CoachCare fees, and the margin the practice retains. Month 1 carries the one-time implementation and integration setup.
24-month net reimbursement by code family, recommended cohort. Net is apportioned across codes in proportion to gross billed.
| Program | Net reimb. | Program cost | Practice margin |
|---|---|---|---|
| Remote monitoring — devices, data & management | $1,646,725 | $903,939 | $742,786 |
| Implementation, athenaOne integration & outreach | — | $40,753 | −$40,753 |
| 24-month total | $1,646,725 | $944,692 | $702,033 |
The cohort is what we recommend. Panel-wide is what the opportunity looks like if you eventually screen all 5,000 — shown so the ceiling is visible, not because it is the plan. Note how little it adds: screening the other half of the panel yields only 131 more patients, because the cohort already contains most of the monitoring-appropriate population. Both are priced identically and both are monitoring-only.
| Configuration | Net reimb. | Practice margin | Margin % | Patients at M24 | Avoided admissions |
|---|---|---|---|---|---|
| High-risk cohort — ~2,500 screened Recommended | $1,646,725 | $702,033 | 42.6% | 744 | ~106–213 |
| Panel-wide — all ~5,000 screened Ceiling | $1,906,292 | $813,811 | 42.7% | 875 | ~123–246 |
$1.60M to $3.19M of avoided cost, depending on the cohort's true baseline admission rate.
Over 24 months, after all CoachCare fees, at a 42.6% practice margin — positive from month one.
About 5.5 FTE-years of monitoring, documentation and outreach labor absorbed by CoachCare.
Continuous objective data on the patients driving your utilization.
With twenty-two referring clinicians and a full-time enrollment specialist, your outreach capacity is roughly 141 referrals a month before the specialist adds anything. Against a cohort ceiling of 744 patients, that saturates in six months and then holds flat through month 24 — the census at month 12 and at month 24 is the same number.
That flat line is the useful finding: your constraint is the cohort definition and the consent rate, not outreach capacity. Adding clinicians or a second enrollment specialist would not move this number at all. The two levers that do are widening the cohort — deliberately, where the clinical and benchmark case supports it — and consent rate, which is why it is a slider below.
The sliders drive the same enrollment engine and the same per-patient economics as the Value Analysis. At the default positions it reproduces the recommended cohort exactly. Note how little the clinician and specialist sliders move the result — and how much cohort size and consent rate do.
Patients in active monitoring. Cohort eligibility is held at the high-risk profile throughout.
Avoided admissions here use the model's conservative 20% baseline annual admission rate. For a true heart-failure and advanced-CKD cohort the realistic figure is roughly double — see the sensitivity table above.
Launch requires no capital, no hiring, and no second system. The work in the first month is clinical agreement and configuration, not construction.
Pull the real cohort from athenaOne — heart failure, CKD 3b–4, COPD, and uncontrolled hypertension and type 2 diabetes — which replaces the estimate behind every number on this page. In parallel, confirm against the current payment specifications exactly where the care-management-fee offset begins and ends, so the configuration is right on day one rather than corrected later.
Agree monitoring thresholds by condition, name the clinician each non-critical escalation routes to, and confirm the emergent protocol. This is the session that makes the governance model yours — and the one your care manager should lead.
Bi-directional integration configured and tested: enrollment flags, discrete vitals write-back, escalation tasks, and automated claim generation.
The CoachCare-funded specialist begins in your office, referral capture starts at the visit, and the first cohort is monitored and billing within days of consent.
Remote care programs fail on operations, not on clinical intent. Scale is the only real evidence that the operations work.
Across more than 400 managed conditions.
Providers running remote care programs on the CoachCare platform.
Programs launched and operating in market.
Care-plan coding and billing at production scale.
Plus more than 4 million care actions enabled.
From consent to monitored and billing, inside athenaOne.
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. This forecast models RPM alone, so the proposal does reach it — but only by the amount below, and the care-management codes it leaves untouched are available to this service line as added, unaffected revenue.
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.
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.
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% |
| 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 Annapolis Internal Medicine specifically, not remote care in general.
CoachCare integrates bi-directionally with athenaOne: eligibility flags and orders leave the EHR, and discrete vitals, care documentation and claim-ready charges come back into it. One chart for the 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 practice inherits a running program the month it turns on, at a 42.6% 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 physicians and fourteen advanced practice providers already bill through. CoachCare supplies the staff, devices, platform and billing preparation under that governance.
The recommended Year-1 scope is a 2,500-patient high-risk cohort: heart failure, CKD stage 3b to 4, COPD and poorly controlled hypertension. APCM and CCM run together on that panel under a single care-management spine, and the fee-for-service population, which grew 3.1% year over year while Medicare Advantage fell, is where they bill per claim.
The practice has run an Enhanced-Track Shared Savings ACO, the highest-risk track, with two-sided risk since January 2025, and it participates in Maryland's advanced primary care model. A remote care service line is the connective tissue under both: documented chronic-care management that supports attribution and quality without an institution's infrastructure behind it.
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.