A scalable, profitable remote care service line for Virginia Physicians: remote monitoring and chronic care management for the Medicare panel your ten offices already know, billed under your own NPIs and run by a CoachCare care team inside eClinicalWorks
Medicare is changing what it pays primary care for. Four shifts are under way at once, and each one lands in the same place: the weeks between a patient’s visits. For a practice whose Medicare patients carry hypertension, diabetes and kidney disease together, those weeks decide how the year goes.
Virginia Physicians has cared for Central Virginia since 1923, and it is still physician-owned and physician-governed. Seventy-nine primary care clinicians work across ten offices on one eClinicalWorks system with their own core lab. Their traditional-Medicare patients average 75 years old; seven in ten have hypertension and one in four has diabetes. The group bills inside an Enhanced-track Medicare Shared Savings Program ACO, completes about 9,100 annual wellness visits a year, and already runs transitional care after hospital stays.
An older Medicare panel, average age 75, in which hypertension and high cholesterol are the norm and diabetes, heart disease and kidney disease are common.
70% of the group’s traditional-Medicare patients carry a hypertension diagnosis. Home readings catch what one office reading misses and let the care team adjust medication month to month instead of at the next visit.
25% of the group’s traditional-Medicare patients have diabetes and 17% chronic kidney disease, usually alongside hypertension. Two or more chronic conditions is the patient chronic care management was written for.
23% have ischemic heart disease, 15% atrial fibrillation, 10% heart failure and 11% COPD. The offices already run EKGs and Holter monitoring; daily weight and blood pressure fill in the months between.
Each step below added offices, clinicians or capability. Click through the years. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of Virginia Physicians touches a patient at one moment: an office visit, a wellness visit, a lab draw, a dietitian appointment, a hospital discharge. A remote care service line connects them, so a patient who leaves one visit is still being watched until the next one. Select any part of the practice to see what changes.
Virginia Physicians’ clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the eClinicalWorks system every office already uses, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. eClinicalWorks already holds the diagnoses, vitals, labs and medications. Patients with uncontrolled hypertension, diabetes, kidney disease or several chronic conditions are flagged using criteria the group’s clinicians set, so the right patients surface at a chronic-care visit, at an annual wellness visit, or on an outreach list.
Example criteria. The group’s clinicians set and own the flag logic for each condition.
Patients enter at an office visit, at a chronic-care or annual wellness visit, or after a hospital stay. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 162/96 on three agents and an A1c above 9. The clinician places the remote care order during the chronic-care visit, or at the annual wellness visit.
Cellular cuff and glucometer at home, a welcome call by phone, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the CCM call covers the other conditions.
99454 · 99457 · 99490Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Devices ordered to the home.
Contact within two business days, medication reconciliation, an office visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99490Office visits ↻ care management ↻ physiologic monitoring.
The clinician orders from the chart, or a CoachCare enrollment specialist working in the office enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The routine is set to fit the patient’s day.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in eClinicalWorks to the first billable day of service. Enrollment status is visible in the chart the whole way through, at every office.
Readings that settle are logged in the chart and visible to the clinician without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the clinician or nurse each office designates, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath or stroke signs reported on a call: the care team calls 911 with the patient on the line, then notifies the office. A critical reading on its own goes to the office. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for the practice’s leadership, and a clinical outcomes report for the clinicians.
CoachCare is the only care-management application integrated with eClinicalWorks that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the practice. Sample below at the modeled month-12 census.
A 24-month forecast for a Virginia Physicians remote care service line: remote monitoring and chronic care management across the Medicare panel, priced at Virginia’s CY2026 Medicare rates with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
Two chronic-care visits a year leave 363 days with no data. RPM bills only when a patient takes readings on at least 16 days in a month, so an enrolled patient gives the care team at least 192 days of readings a year.
Hypertension is the most common condition on the group’s panel and the one home monitoring moves fastest. Home averages give the care team a monthly reason to adjust medication, and the documented result is the home number, not one rushed office reading.
Cardiac Solutions, a physician-owned cardiology practice with three West Phoenix offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
Virginia Physicians’ clinicians take part in an Enhanced-track Medicare Shared Savings Program ACO, which is scored on a fixed set of quality measures. Most of them depend on work this program does every month. Select a measure to see how.
Monitoring the panel every day tells the practice who needs to be seen now, not only who is next on the schedule. Patients surface from their home data, not only when they come in sicker.
Nineteen of the group’s clinicians already bill transitional care after hospital stays. The next 30 days decide whether a patient comes back, and remote monitoring and chronic care management carry the patient past them.
Flagged in eClinicalWorks for post-discharge monitoring.
A call within two business days and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly RPM with CCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, a cardiology referral when the trend returns.
Oxygen saturation and symptoms after an exacerbation, with a quick visit before a return trip to the emergency department.
Glucose and BP while medications change after a stay, and a fluid check for patients with CKD.
Patients who carry hypertension or diabetes into recovery stay on their readings until the follow-up visit.
Every code the service line can bill, at CY2026 Medicare rates for Virginia. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Virginia locality 00 (Palmetto GBA, MAC 11302). Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill per patient per month. About 38% of Medicare beneficiaries in Chesterfield, Henrico, Hanover and Powhatan are in Medicare Advantage. Those plans must pay at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families, and the forecast prices every patient at the Medicare amount.
Virginia Physicians can hand CoachCare the remote monitoring and leave care coordination where it sits today, or run both programs through CoachCare. Either way the program is net-positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $2,592,569 | $9,032,779 | $11,625,348 |
| CoachCare cost (program and eClinicalWorks fees) | $1,501,448 | $5,172,408 | $6,673,855 |
| Net to Virginia Physicians after fees | $1,091,121 | $3,860,372 | $4,951,493 |
| Margin to Virginia Physicians | 42.1% | 42.7% | 42.6% |
| By program: remote monitoring $6,354,595 · chronic care management $5,270,753 in net reimbursement. Month 1 runs −$568 while implementation and the eClinicalWorks setup post against a census still ramping; net-positive from month 2. Fee-for-service reimbursement only; no shared-savings dollars are in these figures. | |||
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. The group’s own Medicare chart count is the first thing to plug in. At this panel size the onboarding pace slider moves the answer more than any other.
CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. Drag the slider to see the team grow with the census.
The group’s physicians, nurse practitioners, physician assistants and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. Virginia Physicians would otherwise need to recruit and keep them.
The enrollment specialist working in the offices and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system Virginia Physicians already runs, using its built-in workflows. Clinicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
eClinicalWorks integration overviewThe staff, protocols and eClinicalWorks workflow built for remote monitoring and chronic care management can take on the next programs the group’s panel qualifies for, without a second hiring plan.
APCM pays a monthly amount per patient in place of CCM, tiered by complexity, to a practice that runs the whole panel. Virginia Physicians can bill it today, and its Shared Savings Program participation fits the accountable-care model APCM was built around. Moving patients from CCM to APCM is a program decision to make together.
About one in six traditional-Medicare patients carries depression, and the group screened about ~5,600 for it in CY2024, with a psychiatric-mental-health nurse practitioner now on staff. Behavioral health integration fits the same care-manager calls and the same chart.
Nineteen of the group’s clinicians already bill transitional care. The same care team can make the two-business-day call after every discharge, so more of them qualify, billed by the group.
Six reasons this partnership fits Virginia Physicians specifically, not remote care in general.
Annual wellness visits, its own core lab, dietitians, EKG and Holter monitoring, and transitional care after hospital stays are already part of the week across ten offices. Remote monitoring and chronic care management fill the months between them.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible at every office.
CoachCare’s care managers carry the caseload at 165 patients each. Enrollment, devices, business-hours alert triage and billing preparation are on CoachCare’s payroll, and fees are per active patient per month, with no capital outlay.
Virginia Physicians’ clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under the group’s own billing entity and NPIs.
The group’s traditional-Medicare patients average 75. Cellular devices need no home internet, no smartphone and nothing to pair, and outreach runs by phone, so no patient has to learn an app.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions in West Phoenix (case study), half the 30-day readmission rate across 26,689 patients at the same practice (case study), and zero readmissions among 450 advanced heart-failure patients at Iowa Heart (case study).
The ask: a working session to confirm Virginia Physicians’ Medicare chart count by payer, map how chronic care management sits beside the value-based support the group already has, scope the eClinicalWorks integration, and set the order the ten offices go live before the first patient enrolls.
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