19 nephrologists, four offices, rounding at fifteen dialysis units, and a Medicare panel whose kidney disease and hypertension prevalence sits at the ceiling CMS publishes to. The practice already bills care management and already carries total-cost accountability through Kidney Care Choices. What it does not have is a daily signal from the panel between visits. This is that layer: transitional care at discharge, remote blood-pressure and weight monitoring, and principal care management for the months after, staffed and run by CoachCare inside athenahealth, with the practice keeping 42.2% of net reimbursement over 24 months.
Year 1 margin 41.6%, Year 2 42.4%. Enrollment begins in month 1; month 1 runs −$1,369 while setup posts against a small census, and the practice is positive from month 2 onward. The headline is 2,504 unique patients; the enrollment chart shows 3,117 active program enrollments, because a patient on both programs is one patient and two enrollments.
This is not a pitch for something new. The practice's own CY2024 Medicare claims show one of the highest-acuity outpatient panels in the state, a care-management program that already exists, and a precise picture of where the billing stops.
Across 32 billing clinicians and $5.42M of Medicare allowed in CY2024: chronic kidney disease, hypertension and hyperlipidemia all report at 75%, the ceiling CMS publishes to · diabetes 62% · heart failure 48% · ischemic heart disease 51% · atrial fibrillation 33%. About 4,800 established patients were seen for a follow-up visit in the year, and roughly 3,800 beneficiaries were followed in the hospital.
Nineteen clinicians billed 99490 in CY2024 for 946 beneficiaries. That is the hard part, consent and a monthly documented touch, already in the practice's habits. The program bills about a quarter of the months it could: 2,802 claims on 946 patients is roughly three billed months per patient per year, and about one established patient in five is in it.
99453, 99454, 99457, 99458 and 99495/99496 are absent from the CY2024 claims for every clinician: no program at meaningful scale. On a panel where three patients in four carry hypertension and one in two carries heart failure, no blood pressure or weight is being read between visits, and the 3,800 hospital follow-ups produced no transitional-care claim.
Columbia Nephrology Associates is a participant in the CMS Kidney Care Choices model through Carolina Kidney Partners, a physician-led Kidney Contracting Entity in the Professional option since the model's first performance year. Under that arrangement the practice's physicians share in savings and losses on the total cost of care for aligned late-stage CKD and dialysis patients, are scored on quality, and are paid on optimal dialysis starts. The entity supplies analytics and care coordination at the network level. What it cannot produce is a daily physiologic signal from each practice's own panel between visits. That layer belongs to the practice, and it is the instrument the contract's economics reward.
The model's current performance period ends December 31, 2026. Whatever follows it, and CMS has said the destination is risk-based, per-member payment reconciled against outcomes, will score the same things: fewer unplanned admissions, more planned starts, more home dialysis, and documented monthly management of the patients most likely to crash into the hospital. A service line that produces those results as fee-for-service margin today is the practice's position for that negotiation.
CMS lists the entity in the CY2026 participant file; the entity's own roster lists this practice's 19 nephrologists and 11 advanced-practice clinicians.
As published by the entity from its CMS results; the multi-year average is 89.2%.
The CMS-measured rate for the entity: patients who start dialysis with a planned access, at home, or with a pre-emptive transplant.
Fluid overload and uncontrolled pressure are what turn a stable CKD 4 patient into an admission and a crash start. Both are visible days ahead on a cuff and a scale, and invisible between quarterly visits.
A CKD admission that does not happen is fee-for-service margin for the service line and, for an aligned patient, a dollar that stays under the entity's benchmark. The same program writes to both.
At the model's generic 20% annual admission rate. A CKD 3b–5 cohort with 48% heart-failure prevalence admits well above that; at 40% the figure is about 408.
At $15,000 per admission, before any shared-savings split. None of it is in the Value Analysis below, which prices the fee-for-service codes only.
| Annual admission rate | Avoided, 24 mo | Spend avoided |
|---|---|---|
| 20% | 204 | $3.06M |
| 30% | 306 | $4.59M |
| 40% | 408 | $6.12M |
| 50% | 510 | $7.64M |
The 40% row is the realistic one for this panel.
Three billing families, one clinical workflow, one care team. A patient enters wherever they are, coming out of the hospital, newly overloaded, freshly cannulated, or overdue for real between-visit management, and stays on the same pathway through progression, access placement and the transition to dialysis or transplant.
Palmetto GBA, South Carolina's single statewide locality: every office and every dialysis unit prices on the same rail.
| Code | What it covers | CY2026 rate | Cadence |
|---|---|---|---|
| 99496 | Transitional care management, high complexity, face-to-face within 7 days | $284.94 | Once per discharge |
| 99495 | Transitional care management, moderate complexity, within 14 days | $209.97 | Once per discharge |
| 99453 | Remote monitoring, patient set-up and education | $20.01 | Once per episode |
| 99445 | Device supply, 2–15 days of readings (new for CY2026) | $48.12 | Short window |
| 99454 | Device supply, 30 days of readings | $48.12 | Monthly |
| 99470 | Monitoring management, 10–19 minutes (new for CY2026) | $24.81 | Monthly |
| 99457 | Monitoring treatment management, first 20 minutes | $49.29 | Monthly |
| 99458 | Monitoring treatment management, each additional 20 minutes | $39.72 | Monthly |
| 99426 | Principal care management, clinical staff, first 30 minutes | $65.02 | Monthly |
| 99427 | Principal care management, each additional 30 minutes | $51.68 | Monthly |
CY2026 Physician Fee Schedule non-facility amounts for ZIP 29203 (Palmetto GBA, South Carolina locality 01), the basis the Value Analysis below is priced on.
CoachCare is an athenahealth integration partner. Enrollment flags and orders leave the chart; vitals, care documentation, enrollment status and billing-ready claims come back into it. Clinicians stay in athenaOne, and the practice's billing team does not learn a new claim path.
Enrollment flags and ordering by service inside the athenaOne workflow; the on-site specialist works the list, and patients begin receiving services within days.
Evidence of care, vitals and care plans attach to the patient's chart monthly, which is what makes the time-based claim defensible under audit.
The CoachCare billing engine creates the claim for every enrolled patient every month, removing the manual claim step the practice's billing team would otherwise carry.
Integration setup for athenahealth runs $1,000 one time, with a $150 monthly interface fee and $1.50 per enrolled patient per month. Those figures are carried in the financial summary below and confirmed in contracting.
The Value Analysis shows the program pays. This is the part that says it is safe, and that 19 nephrologists see signal rather than a thousand readings a day.
Chest pain, new shortness of breath, stroke signs, syncope, sudden swelling, a bleeding or non-thrilling access. CoachCare's urgent and emergent policy supersedes any practice-specific preference. If the patient refuses, the clinic is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or nurse the practice designates in the charter, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a clean symptom check closes the loop with a chart note and nothing else. The nephrologist'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 visit or hospitalization in the preceding 60 days triggers three touches inside two weeks, and when the patient was admitted it is also the TCM episode. The same cadence follows an access placement and the first weeks of a dialysis start. On this panel, that cadence is where the modeled 204 avoided hospitalizations over 24 months come from.
Reach the patient, reconcile medications and the fluid and potassium plan against the discharge instructions, confirm the cuff and scale are transmitting.
Weight and pressure trend reviewed, diuretic or antihypertensive plan confirmed with the nephrologist, follow-up appointment confirmed with the practice.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + PCM stack: 8,540 Medicare patients in scope, the practice's estimated panel, sized from its own CY2024 established-visit beneficiaries and the Medicare Advantage share of its four counties. 30 referring clinicians, one CoachCare-funded on-site enrollment specialist, South Carolina locality rates and the athenahealth integration. Shared savings and transitional care are not in these numbers.
| Program | Net reimbursement | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM: devices, data and management | $2,825,604 | $1,591,364 | $1,234,240 |
| PCM: principal care management | $942,760 | $491,070 | $451,690 |
| Implementation, athenahealth integration and outreach | — | $94,754 | −$94,754 |
| 24-month total | $3,768,364 | $2,177,189 | $1,591,175 |
| 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: 42.2% of net reimbursement (Year 1 41.6%, Year 2 42.4%).
Year 1 is $390,079 net to the practice on $936,821 of net reimbursement; Year 2 is $1,201,096 on $2,831,543. Month 1 is −$1,369 as the one-time setup lands ahead of the ramp; monthly net is positive from month 2 onward.
Recurring professional-fee volume over 24 months, generated inside athenahealth.
Blood pressure, heart rate and weight, a continuous picture of the panel between visits, triaged before a nephrologist sees any of it.
About $3.06M in acute-care cost that never gets spent, at $15,000 per admission. Under Kidney Care Choices that is cost the practice is measured on.
About 33,148 care-team hours of monitoring, outreach and documentation carried by the service line, not by the practice's staff.
Two constraints, one per program. Remote monitoring reaches its eligibility ceiling in month 21; from there its census holds and the only way up is a wider cohort or a higher acceptance rate from the chart. Principal care management is the opposite case: at month 24 it holds 876 of a 2,178 ceiling, so its constraint is enrollment pace, and every unit of enrollment capacity keeps moving it.
| Program | Enrollment ceiling | How it is defined | Month 24 |
|---|---|---|---|
| RPM | 2,242 | 8,540 in scope × 75% eligible × 35% acceptance | 2,242 |
| PCM | 2,178 | 8,540 in scope × 85% eligible × 30% acceptance | 876 |
| At month 24 | — | Active program enrollments = 2,504 unique patients | 3,117 |
Eligibility is set for a nephrology Medicare cohort. Every point of eligibility or acceptance the practice's own chart data supports beyond these raises the monitoring ceiling, and the forecast, directly. Year 1 lands at 1,405 unique patients.
| Enrollment staffing | 24-mo net reimbursement | Net to practice | Unique, M24 |
|---|---|---|---|
| Practice referrals only, no on-site specialist | $2,795,697 | $1,174,365 | 2,078 |
| One CoachCare-funded on-site specialist (this forecast) | $3,768,364 | $1,591,175 | 2,504 |
| Two specialists | $4,498,667 | $1,908,211 | 2,596 |
| Three specialists | $5,089,765 | $2,168,116 | 2,688 |
A second specialist reaches the monitoring ceiling months sooner and keeps lifting the care-management census, which is why the month-24 unique count moves here where it would not on a panel that fills in a year. Without a funded specialist the practice's own referral flow reaches well under half the forecast.
CoachCare operates as the service line's engine while the practice's nephrologists govern protocols and every clinical decision. Full-service delivery means launch needs no new hires, the athenahealth integration is native, and the transitional-care path produces cash before any device ships.
Agree the escalation routing and who receives non-critical alerts. Pull the CKD 3b–5, resistant-hypertension and heart-failure cohorts out of athenahealth, reconcile them against the existing care-management panel, and confirm the enrollable list against the panel estimate in this analysis.
Turn on the athenahealth integration, configure the time-capture and code mapping, and run a claims test on the transitional care management path first.
The funded specialist starts at the Columbia office, working from the confirmed cohort list, then extends to West Columbia, Lugoff and Sumter. Devices ship to enrolled patients. First readings arrive and the escalation engine goes live with the practice watching every route.
The census builds toward the ceilings in the analysis. Blood-pressure control, fluid management, post-discharge touches and planned-start documentation accumulate as retrievable reports, which is what the Kidney Care Choices quality measures and any successor model both need.
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 on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over 5 million claims. The billing path is not an afterthought here; it is the part most remote-care programs get wrong.
Over 100 million vitals recorded and 4 million+ care actions enabled.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposal is narrower than the headline. Here is what it does to the forecast on this page, priced at the South Carolina locality amounts the forecast itself uses rather than national averages.
The proposal reaches the remote-monitoring family only. Principal care management is not in it, and on this forecast PCM carries $942,760 of the $3,768,364 in 24-month net reimbursement. Its own amounts move by well under a point through the conversion factor, so $5,201 of the $270,049 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 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. A practice already inside the Kidney Care Choices model has the reporting habits that arrangement rewards, and the daily data this program produces is what any successor model will score on.
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 shaded reduction can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Palmetto GBA South Carolina locality 01 amounts, non-facility, on this forecast'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 South Carolina locality 01 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: principal care management | ||||
| 99426 | Principal care management, first 30 minutes (clinical staff) | $67.80 | $67.00 | −1.2% |
| 99427 | Principal care management, each additional 30 minutes | $54.11 | $54.52 | +0.8% |
| 99424 | Principal care management, first 30 minutes (physician) | $87.51 | $84.40 | −3.6% |
| 99425 | Principal care management, each additional 30 minutes (physician) | $61.46 | $59.11 | −3.8% |
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 September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare is leading advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
Six reasons this partnership fits Columbia Nephrology specifically, not remote care in general.
CoachCare integrates bi-directionally with athenahealth: eligibility flags and enrollment orders leave the chart, and discrete blood-pressure and weight readings, care documentation and claim-ready charges come back into it. One record for the nephrologists across all four offices, 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 sit on CoachCare's payroll. The practice inherits a running program the month it turns on, at a 42.2% margin, with no hiring cycle. On-site enrollment is our expense, because telephonic outreach converts about 8% and this panel is worth staffing the clinic for.
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 NPIs. CoachCare supplies the staff, devices, platform and billing preparation under that governance. It is the operating model an independent group keeps control of.
This is a low Medicare Advantage market, so most of the panel is traditional Medicare and every RPM and PCM code bills fee-for-service, month after month. For the Advantage minority, the statutory floor pays a non-contracted plan no less than original Medicare, with care-management terms confirmed contract by contract. The mix works in the program's favor here.
The group already carries total-cost accountability through Kidney Care Choices, where broad chronic-care enrollment defends the reconciliation rather than a shortlist. And every hospital discharge across the four offices and fifteen dialysis units opens a transitional-care window. One remote care service line covers both the KCC panel and the post-discharge cohort.
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.