The interstitial layer between quarterly visits — where CKD progression, resistant hypertension, dialysis transitions, and transplant-list stability actually move. Modeled for Georgia's largest independent nephrology group: 20 nephrologists and 11 advanced-practice providers across nine metro-Atlanta offices, built on the practice's existing Epic platform.
Month-24 census is 1,676 active program enrollments (RPM 1,050 + PCM 626); the headline patient figure is 1,238 unique patients after de-duplicating those enrolled in both programs.
This is not a turnaround story. Georgia Nephrology is an independent, physician-owned group — 20 nephrologists and 11 advanced-practice providers across nine metro-Atlanta offices, in its 50th year, with its own clinical-research institute and a modern Epic platform. What it does not have is a remote-care service line. The strategic question is how to turn a large, well-run CKD panel into continuous, billable care between visits — and get paid for the layer that produces it.
20 nephrologists and 11 advanced-practice providers across Gwinnett, DeKalb, Rockdale, Fulton, Hall, and Walton counties — founded in 1976, the largest independent nephrology group in Georgia.
More Georgia Nephrology physicians were named to Atlanta Magazine's 2026 nephrology list than at any other Atlanta group — the referral reputation an independent practice runs on.
The Georgia Nephrology Research Institute runs industry trials in IgA nephropathy and glomerular disease — a data-comfortable culture that adopts new care models early.
Telehealth and a patient portal are in place; no RPM, PCM, or connected-device program is marketed anywhere by the practice — the interstitial layer is unbuilt and unbilled.
One structural gap defines the opportunity: between quarterly office visits, the panel is clinically invisible. No practice-level RPM, PCM, or TCM program runs today — and progression, fluid overload, and unplanned dialysis starts happen precisely in that window.
Total-cost accountability is coming to kidney care, and the independent groups that own the daily signal will define the terms. What changed for 2026 is that the operational answer — continuous, documented management between visits — is cleanly reimbursable at the practice level today, under fee-for-service.
On a Medicare panel of roughly 4,000, about 3,000 patients are eligible for RPM and 3,400 for PCM across CKD and resistant hypertension. None are in a remote-care program today — the entire eligible population is whitespace, and every month of progression between visits is currently unmonitored and unbilled.
New codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) remove the 16-day floor that previously blocked episodic monitoring — making post-discharge windows, post-access-placement recovery, and dialysis-transition stretches cleanly billable for the first time.
Principal Care Management (99426/99427) pays for monthly management of a single dominant condition — and CKD is the archetypal case. For a single-specialty renal panel, PCM carries the monthly care-management layer and stacks with RPM on the same patient, in the same month.
A named, governed service line with its own P&L and scorecard, rather than a device program bolted onto one diagnosis — built for a renal panel: TCM at every discharge, RPM as the daily signal, PCM as the monthly management spine.
| Service | Codes | ~CY2026 Magnitude | Nephrology Use |
|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every hospital discharge across the metro |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$48/mo | 99445 unlocks 2–15-day transition windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$49 + ~$40 add'l | Monthly review, titration, escalation |
| Principal Care Management | 99426 · 99427 | ~$65 + ~$52 add'l | Single dominant condition (CKD) ≥3 months |
The value analysis below uses MAC-locality rates auto-resolved for zip 30046 (Palmetto GBA, Georgia — Atlanta locality).
Before any model upside, the service line must stand on its own P&L. Then the same infrastructure — enrollment, devices, alerts, escalation, documentation, billing — compounds through every layer of kidney-care value the practice already carries.
Georgia Nephrology runs on a nephrology-specific Epic build, with the MyChart patient portal already in patients' hands. CoachCare integrates bi-directionally with Epic — enrollment flags, discrete device vitals, care documentation, and automated claims land in the existing workflow. Clinicians never learn a new system, and patients begin RPM and care-management services in under five days from the moment a physician flags them.
Catalog integration pricing for Epic — one-time setup, monthly maintenance, per-patient fee. Final scope is confirmed in contracting against the practice's exact Epic configuration.
CoachCare is the only care-management platform integrated with Epic that generates claims automatically — removing the manual per-patient, per-month claim step and speeding reimbursement.
A 24-month forecast for the practice: 31 referring providers across nine offices, a dedicated on-site enrollment specialist staffed at CoachCare's expense, MAC-locality rates for zip 30046, and Epic integration. Kidney-model total-cost upside and avoided-admission savings are not in these numbers — they are upside on top.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $509,416 | $1,221,319 | $1,730,735 |
| PCM net reimbursement | $172,738 | $541,931 | $714,670 |
| Total net reimbursement | $682,154 | $1,763,250 | $2,445,405 |
| CoachCare program fees | $372,545 | $981,909 | $1,354,454 |
| Ancillary & one-time fees | $29,191 | $30,843 | $60,034 |
| Practice profit (after all fees) | $280,418 | $750,498 | $1,030,917 |
| 24-month practice margin: 42.2% of net reimbursement. Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value that is never subtracted from the practice profit above. | |||
Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous BP and fluid-status picture of the CKD and hypertension panels between visits.
≈ $1.74M in avoided acute cost at $15K per admission — the crash starts and fluid-overload admissions caught upstream.
20,548 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 Georgia Nephrology's physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new practice headcount; the one-time implementation and EMR-integration fees land in month 1 (the forecast's only negative month), with cumulative breakeven in month 3.
Contracting (EMR product/version confirmation, BAA); Epic integration; standing orders and alert thresholds; enrollment specialist onboarded; chart-count validation of the panel estimate begins.
First cohort enrolled — CKD 3b–5 RPM plus renal PCM. Margin-positive from month two, cumulative breakeven in month three, first monthly scorecard delivered.
RPM census reaches its 1,050-enrollment ceiling in month 15; TCM handoff live across the hospitals the group covers; first quarterly service-line scorecard delivered.
PCM census 316 at month 12 and still climbing — still short of its 1,020 ceiling at month 24, so PCM carries the growth through year two and beyond; home-dialysis persistence and transplant-stability cohorts enrolled; panel validation complete and the Value Analysis re-run on chart counts.
The Lawrenceville headquarters on Hurricane Shoals Road is the natural first wave — it anchors a large share of the Gwinnett panel, sits at the center of the group's hospital rounding loop where discharges surface, and puts the enrollment specialist where office visits, post-discharge follow-ups, and dialysis-education touchpoints already converge.
A main-office-first launch lets one site's physicians and staff shake out the workflow, then produces the internal evidence — census, capture rate, revenue per patient-month, unplanned-start signal — that makes the practice-wide rollout a data decision, not a leap.
| Milestone | Target |
|---|---|
| Epic integration + standing-order sign-off | Day 30 |
| First billable enrollments | Day 30–45 |
| Margin-positive monthly run rate | Month 2 |
| Cumulative breakeven | Month 3 |
| Active program enrollments by Day 90* | ~180 |
| Go / scale decision with full unit economics | Day 90 |
*The modeled months 1–3 practice-wide program census (37 → 97 → 180 active RPM + PCM enrollments), concentrated at the flagship office during the first wave.
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 on CoachCare today.
Remote care programs implemented for provider organizations.
Care-plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions.
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 $714,670 of the modeled $2,445,405 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 $167,419, RPM accounts for $163,199 and the care-management arm for $4,219.
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 Georgia Nephrology 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 the nephrologists, one workflow for billing, 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 42.2% practice margin, with no hiring cycle. On-site enrollment is our expense — 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 practice's own entity and NPIs. CoachCare supplies the staff, devices, platform and billing preparation under that governance — the operating model an independent group keeps control of.
Continuous blood-pressure and weight surveillance is the early-warning layer for chronic kidney disease, the dialysis panel and the hypertension that drives both. Principal Care Management is written for a specialist managing one complex condition and does not require you to be the primary care physician. Both run as one remote care service line.
On the fee schedule the ACCESS Model pays remote care as a risk-based line, and it rewards exactly the between-visit management that keeps CKD and post-discharge patients out of the hospital. The forecast on this page models the reimbursement first; the model readiness sits on top of 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.