The hypertension, type 2 diabetes, heart failure, CKD, and COPD patients your clinicians already care for can generate a recurring, margin-positive revenue line — with the enrollment, device, monitoring, and billing workload carried by CoachCare, not your staff.
Two counts, two different jobs. The headline is 1,239 deduped unique patients at month 24; the enrollment chart and the calculator show 1,900 active program enrollments, because a patient on both RPM and CCM is one patient but two enrollments.
Foster City Medical Center is not starting from zero. The practice already carries the two hardest assets in value-based primary care: a longitudinal Medicare panel it actually manages, and verified participation in two-sided shared-savings risk. What's missing is the service line that converts both into recurring revenue.
Foster City Medical Center appears in the CMS PY2026 Medicare Shared Savings Program participant file under ACO A2098, "The Accountable Care Organization, Ltd." — the ENHANCED track, the program's highest two-sided risk level.
Full-spectrum primary care plus walk-in urgent care under one roof in Foster City — no hospital owner, no private-equity sponsor. This strategy is built to keep it that way.
A multi-clinician internal-medicine and family-medicine roster, Medicare accepted alongside a broad commercial payer panel, and telehealth already offered — the substrate remote care programs bill against.
No RPM, CCM, or PCM program is marketed anywhere on the practice's website — no legacy vendor to displace, and none of this revenue is being captured today.
The chronic-disease work — checking blood pressures, following A1c trends, adjusting meds between visits — is already happening inside this practice. Medicare now pays specifically and recurringly for that work. A remote care service line is how the practice starts collecting.
Care-management billing is the fee-for-service path Medicare deliberately built for practices that manage panels — and the 2026 code set, the practice's live risk contract, and the economics of independent primary care all point the same direction.
New CY2026 codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) remove the 16-day floor that used to block short monitoring windows — post-discharge stabilization, medication starts, and titration checks are now cleanly billable alongside the standard monthly RPM codes.
Through ACO A2098, the practice participates in the Shared Savings Program's ENHANCED track — upside and downside on total cost of care, this performance year. Every avoided admission and better-controlled chronic patient now has a second payoff beyond fee-for-service: shared-savings performance the practice participates in.
Independent primary care can't hire its way to new revenue. This model adds a recurring service line at a modeled ~48% practice margin with the enrollment specialist, devices, 24/7 monitoring, and billing engine funded and operated by CoachCare — no new practice staff required.
A named service line over the whole multi-chronic Medicare panel, with the practice's clinicians governing every protocol and clinical decision, and CoachCare operating everything underneath.
| Service | Codes | ~CY2026 Magnitude | Use in This Practice |
|---|---|---|---|
| Chronic Care Management | 99490 · 99439 | $62.10 + ~$47 add'l | The multi-chronic workhorse — 2+ conditions, 20 min/month |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | Connected BP cuffs, scales, glucometers; 99445 makes 2–15-day windows billable |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $50.66 + ~$41 add'l | Monthly review, titration, escalation |
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every discharge — additive; not in the forecast below |
Dollar figures shown for 99457 and 99490 are MAC-locality rates auto-resolved for zip 94404 (Noridian JE, California locality 05); remaining magnitudes are national non-facility figures.
Off the stack, and off every figure: PCM (99426 · 99427) — a single-dominant-condition code that does not fit a comprehensive primary-care panel, where CCM is the right code. APCM (G0556–G0558) — a build-toward target only, with zero dollars attached.
The forecast below counts only the first layer. The other three ride on the same infrastructure at no additional cost.
Foster City Medical Center runs on Epic — and CoachCare integrates directly and bi-directionally with Epic. Your clinicians enroll and monitor remote-care patients inside built-in Epic workflows, without learning a new system: the whole program lives in the Epic environment.
Enrollment flags and trigger orders sit inside the clinical workflow; CoachCare's team enrolls qualified Medicare patients on the practice's behalf, with enrollment status visible in Epic in real time.
Device readings land as discrete vitals in the chart — not PDFs — alongside an integrated care summary and audit-ready compliance documentation in the record.
The CoachCare billing engine assembles documentation and generates claims automatically — every patient, every month. Your billers submit; nobody reconstructs 20-minute logs.
from enrollment flag to a patient receiving billable RPM and care-management services.
CoachCare is the only care-management platform integrated with Epic that provides automated claims creation via its billing engine.
A program only stays efficient and sustainable if the patient and the provider both work in tools they already know — which is what the Epic integration delivers.
Epic integration fees are already reflected in the forecast below at catalog pricing ($4,000 one-time setup).
A 24-month forecast for the RPM + CCM stack: a 4,200-patient Medicare panel, six referring clinicians, one CoachCare-funded on-site enrollment specialist, MAC-locality rates for zip 94404. PCM is off — a comprehensive primary-care panel is CCM territory, not single-dominant-condition territory. TCM and shared-savings dollars are not in these numbers, and APCM is named only as a build-toward target with zero dollars attached.
| Program | Net reimbursement | CoachCare fees | Practice margin |
|---|---|---|---|
| RPM — devices, data & management | $1,621,527 | $839,609 | $781,917 |
| CCM — chronic care management | $1,593,195 | $780,870 | $812,325 |
| Implementation, Epic integration & outreach | — | $56,906 | −$56,906 |
| 24-month total | $3,214,722 | $1,677,385 | $1,537,336 |
| Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value, never deducted from practice margin. | |||
Year 1 is $370,910 of practice margin on $790,493 of net reimbursement (46.9%); Year 2 is $1,166,426 on $2,424,229 (48.1%) — a growth year, not a flat one; the 24-month margin is 47.8%. Month 1 is −$4,498 as the one-time setup lands ahead of the ramp, and monthly margin is positive from month 2 onward.
Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous clinical picture of the hypertension, diabetes, and heart-failure panels between visits.
≈ $1.27M in avoided acute cost at $15K per admission — accruing to shared-savings performance.
~21,282 care-team hours of monitoring, outreach, and documentation handled by the service line.
CoachCare operates as the service line's engine — enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation — while Foster City Medical Center's physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new practice headcount, the Epic integration follows CoachCare's standard build, and the one discovery item that sharpens this forecast — a chart count to confirm the 4,200-patient panel — is a first-week question.
Run a chart count to confirm the 4,200-patient Medicare panel (discovery item #1). Charter the service line, stand up the Epic integration and billing configuration, sign off protocols for the hypertension, diabetes, heart-failure, CKD, and COPD pathways.
The CoachCare-funded on-site enrollment specialist begins working the panel; connected devices ship to the first RPM cohorts; CCM enrollment runs in parallel. Roughly 155 active program enrollments by day 90.
Enrollment runs continuously through year one, reaching ~1,008 active program enrollments (671 unique patients) and ~$132K/month in net reimbursement at a ~48% practice margin by month 12 — with the ceilings still well above the census.
Year 2 is a growth year, not a flat one: RPM reaches its modeled ceiling of 956 in month 22 and CCM its 945 in month 24, ending at ~1,900 active enrollments (1,239 unique patients) and ~$248K/month in net reimbursement. Because pace — not the ceiling — is the constraint through most of the horizon, a second enrollment specialist pulls this curve forward.
With real enrollment data by complexity tier, weigh the CCM-versus-APCM mix that the practice's verified shared-savings posture makes available — and revisit the panel definition once the chart count is in.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs day to day.
Successful program implementations.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and 4 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 — CCM carries $1,593,195 of the modeled $3,214,722 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 $192,137, RPM accounts for $158,697 and the care-management arm for $33,440.
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 Foster City Medical Center specifically, not remote care in general.
CoachCare integrates bi-directionally with Epic: eligibility flags and orders leave the EHR, and discrete vitals, care documentation and claim-ready charges come back into it. One chart for clinicians, one workflow for the billing team, no second system to stand up.
Enrollment outreach, the care team, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The practice inherits a running program at a 47.8% margin, with no hiring cycle. On-site enrollment is our expense — 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 practice's own entity. CoachCare supplies the staff, devices, platform and billing preparation under that governance — the operating model an independent practice keeps control of.
Advanced Primary Care Management codes G0556 through G0558 are documented and billed monthly on the chronic panel the practice already sees. The mix of monitoring and care management is a deliberate decision, made once, on the patients whose care the practice already owns.
Documented monthly touches and physiologic data on the chronic panel — blood-pressure control, A1c follow-through, medication reconciliation, care-plan documentation — feed exactly the measures MIPS scores an independent practice on. What used to be reconstructed at reporting time is already recorded.
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.