Clinicians on your medical group's roster already run remote monitoring and chronic care management, and it produced roughly $606,000 in Medicare reimbursement in 2024. This is what happens when that same model runs across the whole enterprise — heart failure, CKD, COPD, diabetes and post-discharge patients — funded by fee-for-service reimbursement, and arriving while three CMS programs are scoring the 30 days after a discharge.
Everything in this section comes from CMS's own published files: the Care Compare hospital record for CCN 110089, the CY2024 Physician & Other Practitioners file for the 75 clinicians who bill through Coffee Regional and CRH Physician Practices, and the Medicare enrollment file for the surrounding counties.
Across the enterprise's Medicare panel, against a national reference of 1.00. This panel is 65% sicker than the average Medicare population.
Alongside CKD at 39.1%, diabetes at 41.3%, COPD at 31.1% and atrial fibrillation at 31.3%. Average patient age is 74.4.
37 in CRH Physician Practices across six towns, 28 billing through the hospital — plus a 17-physician hospitalist group.
In Coffee County, and 61.7% across the catchment, against 56.3% for Georgia and 51.7% nationally. Only about one Medicare beneficiary in 2.7 is traditional fee-for-service.
CRH Physician Practices operates clinics in Douglas, Nicholls, Waycross, Alma, Baxley and Hazlehurst — six towns across five counties. The employed group is 15 nurse practitioners, 6 cardiologists, 4 physician assistants, 3 obstetrician-gynecologists, 2 family physicians, 2 general surgeons, 2 urologists, and single specialists in neurology, physical medicine and hematology-oncology.
Coffee Regional First Care is separately certified as a Rural Health Clinic under its own CMS number, and the hospital's internal medicine bench carries six physicians against a residency program.
Heart failure with major complications is the single largest reported DRG at 46 discharges, followed by pneumonia at 43 across two severity levels, sepsis at 17, renal failure at 12 and cardiac arrhythmia at 12. Percutaneous cardiovascular procedures account for another 27.
These are the admissions a remote care service line is built to prevent, and they are concentrated in exactly the conditions the panel already carries.
Sources: CMS Care Compare (CCN 110089); CMS Medicare Inpatient Hospitals by Provider and Service; CMS Physician & Other Practitioners, CY2024; CMS Doctors and Clinicians; CMS Medicare Monthly Enrollment, April 2026. Discharge counts below 11 are suppressed by CMS, so DRG figures are floors.
In CY2024, clinicians on the Coffee Regional and CRH Physician Practices rosters billed roughly $606,000 across remote monitoring, chronic care management and transitional care. That is a working program, not a pilot. The constraint is that it runs on three people, and part of it bills from a second practice location rather than Douglas.
| Program | Codes billed | Patients | CY2024 allowed |
|---|---|---|---|
| Remote physiologic monitoring | 99454 · 99457 · 99458 | up to 268 | $268,026 |
| Chronic care management | 99490 · 99439 · 99487 · 99491 | up to 582 | $288,863 |
| Transitional care management | 99495 · 99496 | 184 | $46,024 |
| Principal care management | 99426 | 20 | $3,551 |
| Total | — | — | $606,464 |
One cardiologist runs essentially the entire remote monitoring book — 212 patients on device supply, 250 on treatment management. A second cardiologist carries 256 chronic care management patients. One internist runs a panel of roughly 18.
99453 covers patient education and device setup at enrollment. It does not appear in the CY2024 file at reportable volume, which means the enrollment work is being done and not billed.
Two internists, two family physicians and one cardiologist, at 13 to 32 patients each — against a hospital that discharges hundreds of chronic-disease patients a year.
CMS Physician & Other Practitioners, by Provider and Service, CY2024, released May 2026. Figures decomposed by CPT. CMS suppresses any provider-code line under 11 beneficiaries, so patient counts are floors and low-volume clinicians may not appear.
Coffee Regional is unusual for a hospital its size: it carries mandatory exposure under one CMS model and preliminary exposure under a second, and both are measured on the period after a patient leaves the building.
Coffee Regional Medical Center appears on the CMS TEAM participant list as a mandatory participant, CCN 110089, in CBSA 20060 (Douglas, GA), for the performance period January 1 2026 through December 31 2030. It is the only hospital in its CBSA on the list.
TEAM reconciles all Medicare Part A and Part B spending for 30 days following a qualifying surgical discharge. Your exposure sits in orthopedic and abdominal episodes — hip and femur fracture treatment is the one episode category visible above the CMS reporting threshold. The volume is modest. The accountability is not optional.
What moves an episode's cost is what happens after discharge: readmissions, emergency department returns, post-acute utilization. None of that is staffed today.
CBSA 20060 is on the CMS mandatory geography list for the Ambulatory Specialty Model. Two heart-failure cardiologists who reassign their Medicare billing to Coffee Regional Medical Center are named on the CMS preliminary participant list for the model.
ASM scores specialists on heart-failure cost and quality. The payment adjustment runs −9% to +9% for the first two performance years and widens to −12% to +12% by the final year. The first performance year is CY2027, paid out in payment year 2029.
Heart failure is already your largest inpatient DRG and your highest-prevalence chronic condition. The same patients drive both models.
Coffee Regional Medical Center Inc is a participant in TC2, LLC on the CMS Shared Savings Program PY2026 roster — ENHANCED track, which is full two-sided risk and the highest risk level in the program. Your hospitalist group and four other Douglas entities are in the same ACO, which also holds a SNF three-day rule waiver.
That changes what this service line is worth. Under two-sided risk, an avoided admission is not just a readmission you were not penalized for — it is total-cost-of-care performance on an assigned population, and the ACO has an operational reason to fund the capability rather than debate it.
Georgia received $218.9 million from the federal Rural Health Transformation Program, administered by the Department of Community Health as the GREAT Health Program. Eighty rural hospitals were each awarded $750,000 for AHEAD model pre-implementation.
Coffee Regional Medical Center appears on Georgia's Value-Based Care Hospital List, designated Rural, current as of July 22 2026. The capability described in this document is what that money is for.
CMS added 99445 for device supply covering 2–15 days of readings, and 99470 for 10–19 minutes of treatment management. Before 2026 a patient who transmitted for eight days in a month, or a month that needed twelve minutes of clinical time, produced nothing billable.
The short-window codes carry patients who would previously have fallen through the 16-day and 20-minute floors — revenue that did not exist when the cardiology program on your roster was built.
TEAM, ASM and the Shared Savings Program all attribute fee-for-service beneficiaries. In Coffee County that is 2,932 people out of 7,669 — the rest are in Medicare Advantage. The models therefore run on the smaller part of your Medicare book.
The service line does not. It bills across the whole panel, which is why the fee-for-service economics stand on their own before a single episode is reconciled.
Sources: CMS TEAM participant list, rendition as of April 15 2026; CMS ASM mandatory geographic areas file (235 areas, OMB 2023 CBSA codes); CMS Ambulatory Specialty Model Participants, CY2027 preliminary file, matched by individual NPI; CMS Shared Savings Program PY2026 participant file; Georgia Department of Community Health, July 23 2026, and the Georgia Value-Based Care Hospital List; CY2026 Medicare Physician Fee Schedule final rule; CMS State/County Medicare Advantage Penetration, July 2026, and Medicare Monthly Enrollment, April 2026.
CMS reduced Coffee Regional's FY2026 inpatient payments by 0.25% under the Readmissions Reduction Program. Of the five measures with a reported excess readmission ratio, three are above 1.0 — and all three are conditions a remote care service line is built to manage.
| HRRP measure | Eligible discharges | Excess readmission ratio | Penalized |
|---|---|---|---|
| Heart attack | 41 | 1.0528 | Yes |
| COPD | 70 | 1.0390 | Yes |
| Heart failure | 120 | 1.0076 | Yes |
| Pneumonia | 172 | 0.9637 | No |
| Hip / knee replacement | 3 | 0.9866 | No |
CMS FY2026 Hospital Readmissions Reduction Program payment adjustment factors and supplemental data file. Payment adjustment factor 0.9975. A ratio above 1.0 means more readmissions than CMS predicts for a comparable case mix.
Pneumonia is the one chronic-disease measure you are not penalized on — and it still carries a problem. CMS flags excess days in acute care as More Days Than Average on 172 discharges while the readmission rate itself is unremarkable at 15.4%.
Excess days count emergency department visits and observation stays that readmission measures ignore. In the same year, 490 Medicare beneficiaries passed through comprehensive observation services against 435 inpatient beneficiaries — more patients held for observation than admitted.
Heart failure is your largest inpatient DRG at 46 discharges, your highest-prevalence chronic condition at 34.1% of the panel, a penalized HRRP measure, and the clinical anchor of the Ambulatory Specialty Model your cardiologists are named on. Four separate CMS programs point at the same cohort.
A heart-failure patient's risk concentrates in the fortnight after discharge, when weight and blood pressure drift before symptoms return. That period is currently unstaffed — there is no daily reading, no scheduled touch, and no trigger short of the patient calling.
Coffee Regional's FY2026 Hospital Value-Based Purchasing total performance score is 30.50 out of 100. Safety scores 65, consistent with six consecutive Leapfrog "A" grades. But Clinical Outcomes scores 10 and Efficiency & Cost Reduction scores 10 — the two domains a remote care service line moves most directly, and the two furthest from where the rest of the scorecard sits.
Across 133 open requisitions there is no care coordinator, no population health role, no transitional care nurse, no health coach and no remote monitoring position. The post-discharge window is not under-resourced — it is unstaffed, and every measure above is describing the same gap from a different angle.
The patient is flagged in the chart before they leave. Transitional care management starts the clock — a code five of your clinicians already bill.
Medication reconciliation, symptom check, device set up and paired. Readings begin transmitting the same week.
Weight and blood pressure trends reviewed against the discharge baseline. Drift is caught here, days before it becomes a presentation.
The patient either transitions into longitudinal monitoring and chronic care management, or is stepped down. The 30-day episode window closes with a documented record.
Sources: CMS FY2026 HRRP payment adjustment factors and supplemental data file; CMS Care Compare unplanned-visits file for CCN 110089, current rendition; CMS Medicare Outpatient Hospitals by Provider and Service, CY2024 (APC 8011); CMS FY2026 Hospital Value-Based Purchasing total performance score.
The specialty arm runs on the cardiology and internal medicine bench. The primary care arm runs on the employed group and the Rural Health Clinic. Both feed the same enrollment engine, the same escalation logic and the same billing pipeline.
Heart failure, resistant hypertension, CKD stages 3b–4 and COPD. Daily weight, blood pressure and pulse oximetry against a defined baseline, with titration decisions routed to the treating physician.
Remote monitoringPost-discharge cadenceHeart failure cohortThe multi-chronic panel that 15 nurse practitioners, the family physicians and the internal medicine bench already manage: hypertension, diabetes, hyperlipidemia and the patients carrying three or more of them at once.
Chronic care managementSix-town footprintRural Health ClinicEvery rate below is the CY2026 Medicare Physician Fee Schedule non-facility amount for MAC locality 1021299, which is the locality your ZIP resolves to.
| Code | Service | 2026 rate | Cadence |
|---|---|---|---|
| 99453 | Remote monitoring setup and patient education | $19.57 | Once per episode |
| 99454 | Device supply, 16 or more days of readings | $46.58 | Monthly |
| 99445 | Device supply, 2–15 days of readings (new for 2026) | $46.58 | Monthly |
| 99457 | Treatment management, first 20 minutes | $48.78 | Monthly |
| 99458 | Treatment management, each additional 20 minutes | $39.55 | Monthly |
| 99470 | Treatment management, 10–19 minutes (new for 2026) | $24.56 | Monthly |
| 99490 | Chronic care management, first 20 minutes | $63.30 | Monthly |
| 99439 | Chronic care management, each additional 20 minutes | $48.01 | Monthly |
Transitional care management (99495, 99496) is the on-ramp at every discharge and is already billed by five of your clinicians. It is not included in the forecast below, which models remote monitoring and chronic care management only.
A CoachCare enrollment specialist works on site at Coffee Regional's expense to no one's payroll but ours. Patients are identified from the chart, consented, and set up with cellular devices that need no wifi, no app and no smartphone — which matters across a rural six-county footprint.
Readings route through one escalation engine with defined thresholds and a documented trend definition. Your team sees signal — the clinical decisions and the exceptions — not 354,000 raw readings.
Time, touches and care-plan actions are captured as they happen and assembled into claims automatically. Over 24 months the model generates roughly 126,000 claims without adding a biller.
Your two environments are split: the hospital runs Paragon with a FollowMyHealth portal, and CRH Physician Practices runs athenahealth on practice tenant 9964, shared across cardiology, oncology, the women's center and bariatrics. Remote monitoring and chronic care management live on the ambulatory side — which is the athenahealth side, and which has a well-trodden integration path.
Enrollment flags and trigger ordering sit inside the existing clinical workflow. Our team enrolls qualified Medicare patients on the practice's behalf, and enrollment status is visible in the chart in real time.
Problem list, medications and history flow bi-directionally at intake, so the care team starts from the record rather than from a phone call.
Device readings land in the chart as discrete, trendable vitals — not PDF attachments a physician has to open one at a time.
An out-of-range reading that needs the practice becomes a task in the system your team already works, routed to the person who should see it.
Time, touches and care-plan updates are written into the record as an audit-ready care summary, which is what a care-management audit actually asks for.
Claims are created by the CoachCare billing engine, removing the manual claim step for each patient every month. Patients begin receiving services in under five days from the enrollment flag.
Every reading from every patient in both arms routes through one escalation engine. The rules do not change by program, by clinic, or by who is on shift.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache or sudden swelling trigger a 911 call with the patient still on the line. If the patient refuses, they are directed to the clinic; if they refuse that and the presentation is emergent, CoachCare activates 911.
911 activated with the patient on the line, and the practice notified.
Routed to a named member of the practice team, defined during implementation rather than improvised.
Documented in the record as an FYI. No interruption, no task, no noise.
Re-escalated on a fixed cadence, with the practice notified at every decision point.
Modeled on an in-scope population of 7,800 patients drawn from a Medicare panel of roughly 12,000, with 50 referring clinicians and one CoachCare-funded on-site enrollment specialist. Rates are the CY2026 fee schedule at your locality.
| Year 1 | Year 2 | 24-month | |
|---|---|---|---|
| Net reimbursement | $2,197,579 | $4,135,267 | $6,332,846 |
| CoachCare fees | $1,279,145 | $2,347,249 | $3,626,394 |
| Margin retained by Coffee Regional | $918,434 | $1,788,018 | $2,706,452 |
| Margin % | 41.8% | 43.2% | 42.7% |
Over 24 months, after all CoachCare fees, at a 42.7% margin. Month one clears positive.
Modeled across the monitored population over 24 months, concentrated in the heart failure and COPD cohorts.
In active remote care at month 24, deduplicated across patients enrolled in both programs.
56,194 hours of care-team work over 24 months, delivered by CoachCare rather than recruited into a rural market.
This calculator runs the same enrollment engine as the Value Analysis and reproduces it exactly at the default settings. The most informative thing it shows is which lever actually matters here.
Pull the actual chart count of patients carrying a qualifying chronic condition across CRH Physician Practices, the hospital clinics and First Care. The forecast uses 7,800 against a Medicare panel of roughly 12,000; the real number sets the ceiling, and it is the single input worth confirming first.
The cardiology remote monitoring panel is running today. Extending it is faster than starting anywhere else, and it lands directly on the heart-failure cohort that both CMS models score.
Wire the discharge trigger, the three touches and the escalation routing. This is the piece that touches the TEAM episode window, the pneumonia excess-days measure and the heart-failure population at the same time.
Six towns, 37 clinicians, and a Rural Health Clinic. Same engine, same escalation rules, same billing pipeline — run by the enrollment specialist rather than by your clinic managers.
Across more than 400 managed conditions.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than five million claims.
Over 100 million vitals recorded and 4 million care actions enabled.
Every figure on this page, with the sourcing and the model inputs behind it.
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