The Medicare patients Valley Clinics already manages in Corvallis, Albany and Salem carry the conditions Medicare pays to manage between visits: hypertension in seven of ten, diabetes in three of ten, chronic kidney disease in nearly three of ten. The practice is inside a full-risk ACO arrangement that rewards the same work. This is the 24-month plan to bill for it inside Practice Fusion, with CoachCare staffing the program, at no capital cost and with no new hire.
Two counts, two jobs. The headline is 425 unique patients at month 24; the enrollment chart and the Scenario Explorer show 652 active program enrollments, because a patient on both RPM and CCM is one patient and two enrollments.
A privately owned adult primary care practice with offices in Corvallis, Albany and Salem, a Patient-Centered Primary Care Home certification from the Oregon Health Authority, thirty-minute visits by design, a Medicare population whose own claims show the conditions remote care manages best, and a full-risk ACO arrangement that pays for keeping those patients out of the hospital. What is missing is the service line.
Three physicians and six advanced practice clinicians in adult primary care and internal medicine, with integrated behavioral health alongside them. Every one of them is a referral source for the program, and every office is a place a Medicare patient can be enrolled.
CY2024 Medicare claims for the practice's clinicians show hypertension in 71% of beneficiaries, diabetes in 30%, chronic kidney disease in 28%, COPD in 18% and heart failure in 13%, with an average risk score of 1.17 against a national 1.00.
CMS's own eligibility record for 2026 places the practice's clinicians inside an ACO REACH entity on the Global option, the full-risk track. Documented monthly care management is what holds those patients' alignment and what moves the total cost of care the ACO is paid on.
The practice runs a certified cloud EHR with a standard patient-data API and a patient portal already in use. The program integrates with the chart the clinicians already work in; nobody changes systems.
One structural fact completes the picture: no remote patient monitoring, chronic care management or transitional care code appears at meaningful scale in the practice's CY2024 Medicare claims. Fifteen distinct services were billed; annual wellness visits are among them, and every one of the between-visit codes on the next page is absent. The panel and the conditions are here. The billing for managing them between visits is not.
Three things line up for an independent Willamette Valley primary care practice in 2026: richer remote care billing, an ACO model that ends on December 31 and a successor that will want the same documented care management, and a program model that needs neither capital nor a hiring plan to start.
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. A blood-pressure titration or a post-discharge window is now cleanly billable next to the standard monthly RPM stack. On this forecast the two new codes carry about 17% of remote-monitoring reimbursement.
ACO REACH ends on December 31, 2026. Whatever arrangement carries the practice's aligned patients from January 2027 has the same entry requirement as every CMS primary care model announced this year: a consented longitudinal panel, documented monthly care management, continuous physiologic data and a working readmission-prevention loop. This service line builds all four under fee-for-service, before any deadline exists.
Enrollment outreach, care managers, devices and billing preparation are CoachCare's payroll, and fees are per active patient per month. For a practice with a goal of thirteen to sixteen visits a day per clinician and no spare hours in the schedule, the program starts without a build cost and without a hiring plan.
Medicare Advantage covers about half of Benton County's Medicare population and roughly two thirds of Linn and Marion counties'. MA plans must reimburse at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families. The forecast on this page is priced at the Medicare fee schedule for the whole panel; which plans hold the practice's members, and their terms for these codes, is the second thing to confirm after the chart count.
A named service line with its own P&L and scorecard, following the multi-chronic Medicare patient the practice already knows, inside Practice Fusion. The panel runs on RPM and CCM, with transitional care at every hospital discharge the offices learn of. Valley Clinics owns the program, its patients, its protocols and its revenue; CoachCare is the engine underneath it.
| Service | Codes | CY2026, Oregon locality | Use across the panel |
|---|---|---|---|
| Chronic care management | 99490 · 99439 | $65.32 + $49.84 add'l | The longitudinal wrapper; two or more chronic conditions |
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $21.43 setup · $51.80/mo | Hypertension, diabetes and heart-failure cohorts; 99445 opens 2–15-day windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.25 + $40.94 add'l · $25.79 | Monthly review, titration, escalation |
| Transitional care management | 99495 · 99496 | Per discharge | Every hospital or observation discharge the offices learn of; not in the forecast below |
| Advanced primary care management | G0556 · G0557 · G0558 | $16.14 · $53.17 · $115.82/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 97330 (Noridian, Oregon locality 99, which covers all three offices), the basis the Value Analysis below is priced on.
Practice Fusion is a certified cloud EHR with a standard FHIR patient-data API, a patient portal and electronic prescribing. CoachCare integrates over those interfaces: eligible-patient flags and referral orders leave the chart, and monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The integration is priced in the forecast as a custom interface, scoped in a workshop with the practice's administrator and billing lead, and typically runs about four to six weeks alongside onboarding.
typical integration window for a certified FHIR EHR, run in parallel with onboarding, training and care-team assignment.
a clinician flags an eligible patient and submits the referral from inside Practice Fusion; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the practice's own billing department already runs. No PDFs, no re-keying.
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 the clinicians keep 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 office is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or medical assistant each office 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 clinician'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 whose patients are admitted at the two regional health systems and come back to their own primary care home afterwards, that trigger is the discharge summary and the patient's own call. 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 45 avoided hospitalizations over 24 months come from, and under a full-risk ACO arrangement each one is total-cost-of-care arithmetic as well as a patient kept home.
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 office.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + CCM stack: a 1,800-patient Medicare panel across the three offices with 1,440 in scope for Year 1, 9 referring clinicians plus CoachCare's enrollment outreach, Oregon locality rates, and the Practice Fusion integration. Shared-savings distributions, TCM and APCM are not in these numbers.
| Program | Net reimbursement | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM: devices, data and management | $658,449 | $386,603 | $271,846 |
| CCM: chronic care management | $725,196 | $378,491 | $346,705 |
| Implementation, Practice Fusion integration and outreach | — | $31,755 | −$31,755 |
| 24-month total | $1,383,644 | $796,848 | $586,796 |
| 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: 42.4% of net reimbursement (Year 1 41.4%, Year 2 43.2%).
Year 1 is $241,126 net to the practice on $582,623 of net reimbursement; Year 2 is $345,670 on $801,022. Month 1 is −$4,783; every month after month 2 is positive.
Recurring professional-fee volume over 24 months, generated inside Practice Fusion.
Blood pressure and weight, a continuous picture of the hypertension and diabetes cohorts between visits.
About $682K in acute-care cost that never gets spent, at $15,000 per admission. Inside a full-risk ACO, that is total-cost-of-care arithmetic.
About 11,739 care-team hours of monitoring, outreach and documentation carried by the service line, not by the offices' medical assistants and front desks.
RPM reaches its ceiling of 328 enrollments in month 7 and CCM its ceiling of 324 in month 7. From there the census holds at 652 active enrollments, 425 unique patients, for the rest of the 24 months. The constraint on this forecast is the size of the eligible Medicare panel, not outreach capacity: a second enrollment specialist reaches the same ceilings sooner and adds $67,284 over 24 months, and it cannot raise them. What raises them is the chart count and the eligibility definition, which is why the working session starts there.
| Program | Enrollment ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 328 | 1,440 in scope × 65% eligible × 35% acceptance | Month 7 |
| CCM | 324 | 1,440 in scope × 75% eligible × 30% acceptance | Month 7 |
| At month 24 | 652 | Active program enrollments = 425 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. On a panel where hypertension runs above 70% and depression near 30%, there is room.
The first lever is the chart count. The panel behind this page is sized from the practice's own Medicare claims and the Medicare Advantage share of its three counties; a chart pull that shows more Medicare patients than that moves every figure on this page in proportion, and the Scenario Explorer is the tool for reading it off. The second is the eligibility definition: the share of the panel with a qualifying condition, which on this claims profile is conservative. The third is acceptance, which is where a practice with thirty-minute visits and patients who chose an independent clinic on purpose has an advantage the model does not credit.
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 ACO participation. It carries zero dollars on this page. Once real enrollment data exists, and once the arrangement that follows REACH in 2027 is known, 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 clinicians govern protocols and every clinical decision. Full-service delivery means launch needs no new headcount; the Practice Fusion integration runs in parallel with onboarding, and the first enrollments follow the first referral orders from the Corvallis office.
Integration workshop with the administrator and billing lead, FHIR connection built and tested; named program lead; P&L and scorecard; billing configuration with the practice's billing department; protocol sign-off for the hypertension, diabetes and kidney pathways; the ACO's care-management reporting aligned so the same touch counts on both ledgers.
CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts at the Corvallis office; CoachCare's enrollment outreach working the schedule alongside the medical assistants; TCM and the post-discharge cadence live from day one.
The Albany and Salem offices switched on with the same protocols; RPM reaches its modeled ceiling in month 7 and CCM in month 7; monthly scorecard to the owners.
Re-validate eligibility against chart data, decide the CCM-versus-APCM mix once the 2027 ACO arrangement is known, scope behavioral health integration billing, and align the program's documentation with whatever quality and cost measures that arrangement carries.
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 Oregon locality amounts the forecast runs on 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 $725,196 of the $1,383,644 in 24-month net reimbursement. Its own amounts move by about two points, so $15,070 of the $78,795 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.
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. A practice already inside a full-risk ACO arrangement is on the right side of that argument.
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 colour can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Noridian Oregon locality 99 amounts, non-facility, on this panel'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 Oregon 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.
The comment period on CMS-1848-P closed on September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare led advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
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 day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded; 4 million+ care actions enabled.
Six reasons this partnership fits Valley Clinics specifically, not remote care in general.
CoachCare runs bi-directional integrations with the major certified EHRs and connects to a certified FHIR endpoint the same way. Eligibility flags and orders leave Practice Fusion, vitals, documentation and billing-ready claims come back into it. No second system for clinicians, no re-keying for the billing department, and no pressure to change platforms.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. A practice that is already recruiting for a therapist and a Salem clinician does not add a care-management hiring cycle on top; the program arrives staffed, at a 42.4% margin.
Fewer ED visits and admissions among aligned patients are what a Global-option ACO is paid on. The monthly touches that generate care-management revenue are the same touches that produce them, and the documented care plan is what holds alignment. One program, both ledgers, with the fee-for-service margin funding it while the shared-savings benefit accrues.
A recurring service line with its own margin is the alternative to selling the practice to fund the next hire. The revenue on this page is billed under Valley Clinics, governed by its clinicians and owned by its owners. CoachCare supplies staff, devices, platform and billing preparation under that governance, which is the arrangement an independent practice needs.
The clinicians set the protocols, sign the care plans and make every clinical decision; critical readings escalate through one engine whose urgent policy supersedes any preference; and every discharge the offices learn of becomes a TCM episode with the first call already made.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid, which is why the plan is measured twice before it goes to paper. The forecast, the Disclosures and the workbook behind this page are yours to keep either way.