Six nephrologists, one office, and a panel running more than three times the national average acuity — CKD, resistant hypertension, heart failure and the transition to dialysis. A managed remote care service line puts a clinical touch between the quarterly visits, under your own tax ID, on your own P&L.
Modeled on an estimated ~2,050-patient Medicare panel across six nephrologists at 2026 Ohio Medicare rates. Margin is stated as net to the practice ÷ net reimbursement over 24 months. Enrollment specialists are staffed at CoachCare's expense and are never deducted from that margin.
Nothing on this page is inferred from your specialty. It comes from CMS's public Medicare Physician & Other Practitioners file for calendar year 2024, released in May 2026, for the six nephrologists billing under Northeast Ohio Nephrology Associates.
Across the six panels, against a national Medicare average of 1.00. This is among the highest acuity you will find in ambulatory medicine.
Both conditions reach the 75% ceiling CMS publishes. Diabetes runs 49–62%; heart failure 37–48%. This is a remote-monitoring population by definition.
Subsequent hospital-care services in CY2024, plus 227 admissions, across at least six affiliated facilities. Six physicians cannot also staff the space between visits.
Your entire CY2024 Medicare service mix: office visits, hospital rounding, ESRD monthly capitation, hemodialysis. Not one remote-care code.
Across all six physicians, CY2024 shows no claims for remote physiologic monitoring (99453/99454/99457/99458), chronic care management, principal care management, remote therapeutic monitoring, or transitional care management (99495/99496).
Stated precisely, because it matters: CMS suppresses any provider-and-code line with fewer than eleven beneficiaries. What the data proves is that no program at meaningful scale existed in CY2024 — not that literally no patient was ever monitored. Against a twelve-code service mix with no other suppressed footprint, the practical conclusion is the same.
Those 227 admissions also open 227 transitional-care windows. Transitional care is a real, separate opportunity — and it is deliberately not included in any number on this page.
Summit County runs 63.1% Medicare Advantage penetration — Stark 69.0%, Portage 64.3% — among the most MA-saturated markets in the country. The CMS file counts fee-for-service only.
Total Medicare = fee-for-service plus Medicare Advantage at the local penetration rate. That is why the modeled panel is larger than the 1,072 beneficiaries visible in the public file.
It also matters commercially: Medicare Advantage plans reimburse these codes, so the service line bills across your whole Medicare book — while value-based attribution reaches only the traditional-Medicare slice.
Source: CMS Medicare Physician & Other Practitioners — by Provider, and by Provider and Service, CY2024 (dataset released 2026-05-21). Medicare Advantage penetration: CMS MA State/County Penetration, July 2026 file. Comorbidity percentages are CMS-published panel prevalence, capped at 75% by CMS for CKD and hypertension.
You are in a full-risk kidney model with no monitoring infrastructure, in the first year that Medicare pays for the short monitoring windows that make post-discharge and post-procedure care billable.
Northeast Ohio Nephrology Associates is listed by exact legal name as an aligning provider in Integrated Kidney Care of Ohio, LLC, a DaVita-affiliated Kidney Contracting Entity, on the Global option — 100% of shared savings and losses. Cohort 2, performance from January 1 2023, active in PY2026. All six physicians appear on the roster, and one of them sits on the KCE's governing body.
CMS has extended the CKCC options through PY2027. The risk does not run out before a service line could be built and matured.
The KCE's own public disclosure reports a Total Quality Score of 87.5% in PY2023 and 80.0% in PY2024. Under the Global option, the quality score gates the share of savings that can be earned.
The same disclosure reports PY2024 shared savings of $1,491,352, of which 89.2% was retained for infrastructure and care resources and 10.8% distributed to participants and preferred providers. PY2023 distributions were $0.
That is not an argument about anyone's care quality. It is an argument about where the P&L sits: a remote care service line billed under your own tax ID is professional-fee revenue you keep, on a panel far wider than the patients attributed to the KCE.
| 2026 payment change | What it is | Why it matters here |
|---|---|---|
| 99445 | New CY2026 remote monitoring code for a 2–15 day data window, valued like 99454 | Makes short monitoring windows billable — the two weeks after a hospital discharge, an access procedure, or a medication change, where CKD decompensation actually happens |
| 99470 | New CY2026 code for the first 10 minutes of treatment-management time | Pays for the shorter clinical interactions that make up most real remote-care work, instead of requiring a full 20 minutes before anything is billable |
| CKCC through PY2027 | CMS extended the CKCC options by one year | A service line stood up in 2026 has two full performance years to affect total cost of care and quality |
Rates and code definitions are CY2026 and locality-adjusted; Ohio statewide Medicare locality applies here. CKCC participation details are drawn from the KCE's CMS-required public transparency roster and CMS's PY2026 participants and affiliations notices, dated February 4 2026.
CKD does not progress in your exam room. It progresses over the eleven weeks between visits, in blood pressures nobody sees and weight changes nobody logs. The service line is built to occupy exactly that interval.
Cellular-connected blood pressure cuffs and scales — no phone, no app, no Wi-Fi setup. Readings flow continuously; a clinical team watches them and escalates on your rules.
Target cohorts: CKD stage 3b–5 not yet on dialysis · resistant and uncontrolled hypertension · the heart-failure overlap that runs 37–48% of your panel · volume management approaching dialysis transition.
Modeled: 1,538 monitoring-eligible patients · 538 enrolled at the modeled acceptance rate.
A named care manager owning the single dominant condition — chronic kidney disease — with a documented care plan, monthly clinical time, and structured coordination back to the referring primary-care physician.
Target cohorts: advanced CKD requiring modality education and optimal-start planning · patients where the choice between a planned access and a crash start is still open · transplant-candidacy maintenance.
Modeled: 1,742 care-management-eligible patients · 420 enrolled by month 24 and still climbing.
| Code | Service | Cadence | Ohio 2026 rate |
|---|---|---|---|
| 99453 | Remote monitoring — setup and patient education | Once per episode | $19.89 |
| 99454 | Device supply, 16–30 days of readings | Monthly | $47.60 |
| 99445 | Device supply, 2–15 days of readings (new for 2026) | Short windows | $47.60 |
| 99457 | Treatment management, first 20 minutes | Monthly | $49.17 |
| 99470 | Treatment management, first 10 minutes (new for 2026) | Monthly | $24.75 |
| 99458 | Treatment management, each additional 20 minutes | Monthly | $39.71 |
| 99426 | Principal care management, first 30 minutes | Monthly | $65.03 |
| 99427 | Principal care management, each additional 30 minutes | Monthly | $51.62 |
Non-facility rates for the Ohio statewide Medicare locality (carrier 15202, locality 00), CY2026. Remote monitoring and principal care management may be billed together when time and documentation are discrete.
Professional-fee revenue that lands on your P&L, on the whole panel — Medicare Advantage, commercial and Medicaid patients included, not only the beneficiaries attributed to a value-based entity.
Cellular blood pressure cuffs and scales producing an objective, timestamped record between visits — a different category of evidence from telephonic outreach and navigation.
Enrollment, monitoring, triage and documentation are delivered by CoachCare. Your published staff is two administrators and six physicians; this asks nothing of either.
Your team should not learn a second system to run a remote care program. CoachCare's eClinicalWorks integration puts enrollment, documentation and claims where your staff already work.
Enrollment flags and ordering by service surface inside the existing clinical workflow, with enrollment status visible in real time. Patients begin receiving services in under five days.
Evidence of Care, vitals reports and care plans attach to the patient's chart monthly — the compliance record builds itself as care is delivered.
Claims are created by the CoachCare billing engine rather than keyed by hand for each patient every month. CoachCare is the only care-management application integrated with eClinicalWorks that does this.
"Key to achieving a program that is efficient, effective and sustainable is creating a seamless, intuitive user experience for the patient and provider — and that is what our integration with eClinicalWorks accomplishes."
There is a second reason this matters here. Office care is documented in eClinicalWorks, dialysis care in DaVita's and Fresenius's systems, hospital care in the systems at Cleveland Clinic Akron General and Summa. For a group carrying global risk on total cost of care, having no single cross-setting view of a patient is a real exposure. A remote care layer is one of the few things that sits across all of those settings and reports into one place.
The economics prove the service line pays. This is the part that proves it is safe — and that it does not bury your two-person office in alerts.
Escalates immediately, regardless of whether the patient reports symptoms. There is no threshold below which a critical reading waits for the next business day.
Retake and symptom check first. A single high reading is a measurement question before it is a clinical one — this is what keeps false alarms out of your inbox.
Defined, not improvised: three readings at least an hour apart for blood pressure or glucose, or three within seven days for heart rate. A trend is a rule, not a judgment call.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling: emergency services are called with the patient still on the line. If the patient refuses, they are directed to the clinic — and if the presentation is emergent, CoachCare activates 911 regardless. CoachCare's urgent and emergent policy supersedes any practice-specific escalation preference.
Routed to the person you designate, through the channel you choose, with the clinical context already assembled.
Documented as an FYI in the chart. You see that it happened; you are not asked to do anything about it.
Any emergency visit or hospitalization in the previous 60 days triggers a fixed three-touch cadence: day 1–2, day 5–8, day 12–14. Medication reconciliation, symptom check, weight and blood pressure, and confirmation the follow-up appointment exists and will be kept.
With 227 admissions generated in CY2024, this is the cadence that carries most of the ~63 avoided hospitalizations modeled in the analysis below.
Voicemail and a callback window, then re-escalation on a fixed cadence — and if the reading was critical or the trend was met, the escalation proceeds anyway. Every escalation documents the vital, the findings, the contact method, who was reached, the outcome, and the follow-up. Nothing is left to recollection.
Drawn from CoachCare's standard Care Management escalation protocols. Thresholds, routing and the named recipient for non-critical findings are configured with your clinical team during implementation.
Built from an estimated ~2,050-patient Medicare panel across six nephrologists, at 2026 Ohio Medicare rates. Enrollment begins in month 1. Monitoring reaches its modeled ceiling in month 13; care management is still growing at month 24 — so year two is a growth year, not a plateau.
| Financial summary | Year 1 | Year 2 | 24-month |
|---|---|---|---|
| Net reimbursement | $387,939 | $929,216 | $1,317,155 |
| CoachCare fees (incl. setup & integration) | $229,998 | $525,590 | $755,587 |
| Net to the practice | $157,941 | $403,627 | $561,568 |
| Margin (net ÷ net reimbursement) | 40.71% | 43.44% | 42.63% |
| By program · 24 months | Net reimbursement | Fees | Net to practice |
|---|---|---|---|
| Remote Physiologic Monitoring | $864,847 | $484,677 | $380,171 |
| Principal Care Management | $452,308 | $232,688 | $219,620 |
| Implementation, integration & enrollment | — | $38,223 | −$38,223 |
| Total | $1,317,155 | $755,587 | $561,568 |
Month 1 carries the implementation and integration cost and runs slightly negative (−$5,712); the service line is net-positive from month 2 and every month thereafter. Because CoachCare funds the enrollment engine and the on-site specialist, no practice capital is at risk at any point. The specialist's cost is not deducted above.
Over 24 months — roughly $945,000 in avoided admission cost. Under the Global option, avoided admissions count as total-cost-of-care performance on top of the clinical benefit.
Blood pressures and weights that do not exist today between visits — the objective record that makes a CKD progression conversation concrete.
About 5.9 full-time equivalents of enrollment, monitoring and care-management labor CoachCare supplies — against a published administrative staff of two.
Created automatically through the eClinicalWorks integration rather than keyed by hand, patient by patient, month by month.
Avoided hospitalizations are modeled from remote-monitoring patient-months using the analysis's standard assumption and valued at $15,000 each. The headline patient count is deduped unique patients — patients enrolled in both programs are counted once — while the enrollment chart shows total active program enrollments.
The model above is one set of assumptions, and the panel estimate is the one most worth arguing with. Move it — and everything else — and watch the whole 24-month picture recalculate. This runs the same enrollment engine as the Value Analysis, calibrated to your own Ohio rates.
Hospitalizations avoided under this scenario: ~0 over 24 months.
The explorer reproduces the Value Analysis exactly at the modeled settings. It holds pricing, per-program eligibility, attrition and the enrollment ramp constant.
Four steps. The heavy lifting sits on CoachCare's side of the line at every one of them.
Pull the actual chart count and payer mix from eClinicalWorks and replace the estimate. This is the single input that moves the forecast most, and it is a report you already have.
Thresholds, trend definitions, escalation routing, and who receives non-critical findings. Cohort definitions for CKD stage, uncontrolled hypertension and post-discharge.
eClinicalWorks integration, device logistics, and the CoachCare-funded on-site enrollment specialist starts working the schedule. First patients monitored inside the first month.
Monthly enrollment, capture rate, revenue per patient per month, and the clinical measures that feed your KCE quality score. One scorecard, reviewed monthly.
Across more than 400 managed conditions.
Providers running remote care programs day to day.
Successful programs stood up in market.
Care-plan coding and billing delivered at scale, not by hand.
Plus more than 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 — PCM carries $452,308 of the modeled $1,317,155 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 $75,758, RPM accounts for $73,854 and the care-management arm for $1,903.
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% |
| 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 Northeast Ohio Nephrology Associates specifically, not remote care in general.
CoachCare integrates bi-directionally with eClinicalWorks: eligibility flags and orders leave the EHR, and discrete vitals, care documentation and claim-ready charges come back into it. One chart for the six nephrologists, 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 42.63% margin, with no hiring cycle. On-site enrollment is our expense, because telephonic outreach converts about 8%, so we staff the clinic instead.
Your nephrologists 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 six physicians already bill through. CoachCare supplies the staff, devices, platform and billing preparation under that governance.
The service area runs 63.1% Medicare Advantage penetration, and higher in Stark and Portage. That share is real volume, protected by the statutory floor that pays a non-contracted plan no less than original Medicare, while the fee-for-service population is where RPM and PCM bill per claim, month after month. The mix is handled deliberately here, not left to chance.
CKD, resistant hypertension, heart failure and the ESRD transition all reach the enrollment ceiling, and CY2024 shows no remote physiologic monitoring claims across any of the six physicians, so this is a first build rather than a vendor swap. RPM and PCM run together on that panel, with dialysis rounding and post-transition monitoring under the same care-management spine.
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.