Primary Care Associates of Hagerstown — Remote Care Program Review

The observed data

Seven periods of CoachCare billable units

These are units the CoachCare system generated for the enrolled Medicare Advantage cohort. Two lines tell the whole story: one climbs, one does not move.

Device units vs. treatment management units, P1–P7

Same axis, same scale. The distance between the lines is the entire argument.

Units generated by period — oldest to most recent
CPT	Description	P2	P3	P4	P5	P6	P7
99445	Device supply, 2–15 days	9	9	36	58	81	80
99454	Device supply, 16+ days	2	5	7	25	27	21
99453	RPM setup / education	1	0	5	0	2	1
Device units	99445 + 99454 + 99453	12	14	48	83	110	102
99457	Treatment mgmt, first 20 min	0	0	3	0	0	0
99458	Treatment mgmt, add’l 20 min	0	0	0	0	0	0
99470	Treatment mgmt, 10–19 min	1	1	7	3	4	0
Management units	99457 + 99458 + 99470	1	1	10	3	4	0
99490	CCM, first 20 min	0	0	0	0	0	0
99439	CCM, add’l 20 min	0	0	0	0	0	0

Period labels P1–P7 are as supplied; calendar months are pending confirmation. 99445 and 99454 pay the same amount at this locality ($52.70), so the adherence mix between them matters clinically but carries no revenue difference — nothing in this model claims upside from shifting patients between them.

Read carefully. These are CoachCare-system generated billable units. It is not confirmed that they were submitted as claims, nor that they were paid. Reconciling these units against your remittance data is the first item on the open list at the bottom of this page, and it changes the size of everything shown here.

The capture gap

The equipment side is working at 78%. The clinical side is at zero.

Capture is billable units generated per enrolled patient per month, measured against the CoachCare full-service benchmark for a 200-patient enrolled census. Two rows, most recent period.

Device supply99445 + 99454 — equipment in the home, data transmitting

78%

101 units generated130 benchmark

Treatment management99457 + 99458 + 99470 — clinical time reviewing data and acting on it

0 units generated305 benchmark

99453 (setup) is held out of the device row above so the recurring comparison stays clean — it contributed 1 unit against a 1-unit benchmark in the latest period. The model applies the resulting 77.7% device capture across all three device codes, and 0% management capture across all three management codes.

Why this is the whole story. The device codes are the smaller half of the RPM stack — 130 benchmark units against 305 for management. You are capturing most of the smaller half and none of the larger one, while paying a flat fee that does not distinguish between them. That is why the program sits at roughly breakeven rather than returning anything: it is not that the money is being lost, it is that it was never billed.

What the fee buys

Today you pay a flat fee per enrolled patient. Under full service, the monitoring fee is only incurred when a unit is actually generated.

Both columns are modeled on the same 200 enrolled patients, the same fee schedule, and the same collection assumptions. The only thing that changes is who performs and logs the treatment management work.

Current — as observed

Self-service

Device capture77.7%

Management capture0.0%

Net reimbursement$4,946

CoachCare fees−$5,000

Practice staff cost$0

Net monthly margin−$54

Annualized−$643

Effective fee / enrolled pt / mo$25.00

Net collected per fee dollar0.99×

Modeled — at benchmark capture

CoachCare full service

Device capture100.0%

Management capture100.0%

Net reimbursement$19,427

CoachCare fees−$12,403

Practice staff cost$0

Net monthly margin$7,025

Annualized$84,297

Effective fee / enrolled pt / mo$62.01

Net collected per fee dollar1.57×

The RPM swing. Your effective fee more than doubles — and what it returns per dollar goes from 0.99× to 1.57×. You are not buying a cheaper program; you are buying one that bills.

+$7,078

Per month

+$84,940

Per year

The line-by-line build modeled

Every row below is the workbook, unaltered. Units = 200 enrolled × the benchmark rate for that code × capture. Net collected = allowed × 92.625%.

CPT	Bench / pt	Rate	Units now	Net now	Units full svc	Net full svc	Svc fee / unit

CoachCare fee build
Fee line	Basis	Unit fee	Current / mo	Full service / mo

On the current position. At roughly breakeven, today’s program is not costing the practice meaningful money — but it is not returning any either. The honest framing is that the investment has not yet produced a return, and the reason is entirely mechanical: the codes that carry the value require documented clinical time that no one has the capacity to spend or log.

Practice staff cost is carried at $0 in both columns. That is a deliberately conservative choice, and it works against the full-service case. Enrollment, device support and monitoring effort that never becomes a billable unit is real cost the practice absorbs today; the workbook leaves that input at zero until the practice supplies a number, so the current-state margin is not overstated. Fill it in and the gap between the two columns widens.

The second layer

Care management stacks on top of RPM — and is worth more than the RPM program itself

Two routes, both billable alongside RPM. They are mutually exclusive for the same patient in the same month — you choose one, you do not run both. Modeled below on a 600-patient panel, a placeholder pending your actual eligible count.

99490 · 99439

RPM + CCM

Chronic Care Management. Time-based: 20 documented clinical minutes per patient per calendar month. Requires 2 or more chronic conditions.

Net revenue / patient / mo$68.95

CoachCare fee / patient / mo$33.40

Practice margin / patient / mo$35.55

Care management margin / mo$21,329

Full-service RPM margin / mo$7,025

Combined margin / mo$28,354

Combined margin / yr$340,244

Net per fee dollar — CCM layer2.06×

Net per fee dollar — with RPM1.87×

G0556 · G0557 · G0558

RPM + APCM

Advanced Primary Care Management. No minute-tracking. Tiered by complexity; any consenting beneficiary can qualify.

Net revenue / patient / mo$52.11

CoachCare fee / patient / mo$28.40

Practice margin / patient / mo$23.71

Care management margin / mo$14,225

Full-service RPM margin / mo$7,025

Combined margin / mo$21,249

Combined margin / yr$254,991

Net per fee dollar — APCM layer1.83×

Net per fee dollar — with RPM1.72×

These two columns cannot be added together. CCM and APCM may not be billed for the same patient in the same calendar month. Neither can CCM be combined with PCM, TCM (99495–99496), ESRD services (90951–90970), or home health / hospice supervision (G0181, G0182) for the same patient. RPM stacks cleanly with either one.

How to choose

CCM pays more — and asks for the one thing that has not happened yet

At equal panel size CCM models roughly $85,252 per year above APCM. That number is real and it is in the workbook. But CCM is time-based: 20 documented minutes of clinical staff time, per patient, every calendar month, defensible on audit.

That is precisely the discipline the observed data shows has not been sustainable in-house — management units sat at zero across seven periods.
Under full service CoachCare carries the logging, but the audit exposure stays with the billing practitioner.
CCM time and RPM treatment management time may not be double-counted. The 20 minutes supporting 99490 must be distinct from the 20 supporting 99457.
Eligibility is narrower — 2 or more chronic conditions — so the CCM-eligible panel will be smaller than the APCM-eligible panel, which narrows the advantage above.

APCM pays less — and removes the stopwatch entirely

APCM is a flat monthly service by complexity tier with no minute threshold to document. Its operating requirements are structural rather than clerical, which is exactly what a full-service partner is built to carry.

No time-based documentation, so the failure mode that produced zero management units does not repeat.
Any consenting beneficiary can qualify — a wider eligible panel than CCM.
Thirteen service elements must be continuously available, including 24/7 access to a care team member with real-time record access. That is a staffing requirement, not a documentation requirement.
Practices billing APCM must report the Value in Primary Care MIPS Value Pathway. This is a real obligation and needs confirming before you commit.

The recommendation, and why it is not the bigger number. Selling a documentation-dependent code stack to a practice whose demonstrated constraint is documentation is selling the same problem at a higher price. Both paths are shown here at equal weight and the CCM figure is presented honestly — the case for APCM rests on operating risk, not on revenue. If the practice’s eligible CCM panel comes back close to the APCM panel and there is confidence in sustained time segregation, CCM is the better economics. Absent both, APCM is the more durable choice.

The risk that decides everything

Every rate in this model is a Medicare fee-for-service amount. This cohort is Medicare Advantage.

MA plans contract their own rates. Some pay at or near fee-for-service parity. Some pay materially less. Some do not separately pay RPM or APCM at all. This is not a rounding risk — it decides whether the conclusion holds, not just how big it is.

Modeled outcome by MA rate factor — at the current panel and capture settings
MA pays this % of Medicare FFS	Full-service RPM / mo	RPM + APCM / yr	RPM + CCM / yr

Break-even — RPM alone

63.8%

Below this, full-service RPM on its own does not cover its fees.

Break-even — RPM + APCM

58.1%

The care management layer widens the margin of safety.

Break-even — RPM + CCM

53.4%

The most tolerant of a weak MA rate — and the most exposed on documentation.

What this means practically. At 60% of fee-for-service the full-service RPM program alone is underwater. Every figure elsewhere on this page is shown at 100% parity unless you move the MA slider in the next section — and 100% is an assumption, not a finding. Pulling remittance data on 99445, 99454, 99457 and 99458 from your MA plans is the single highest-value thing that can happen before any decision is made.

The same caution applies to coverage, not just rate. Confirm plan by plan that G0556–G0558 and 99490 / 99439 are separately payable at all — some MA plans operate their own care management programs and will not pay these codes to the practice regardless of the fee schedule.

Explore the model

Move the levers. Every figure on this page moves with them.

This runs the same arithmetic as the workbook. Changing the MA rate factor updates the stat tiles at the top, the ledger, both care management paths, and the tables below — nothing on this page is a static number pretending to be a live one.

Care management panel size 600

Patients enrolled in CCM or APCM — never both. Default 600 is a placeholder pending your actual eligible panel count.

MA rate factor 100%

What your MA plans pay as a percentage of the Medicare fee schedule. The single largest uncertainty in this model.

Full-service management capture 100%

Stress test: how much of the treatment management benchmark the CoachCare care team actually converts into billable units. Device capture is held at 100%.

$7,025

$84,297 / yr

Full-service RPM
margin / mo

$28,354

$340,244 / yr

RPM + CCM
combined / mo

$21,249

$254,991 / yr

RPM + APCM
combined / mo

Care management margin by panel size — at the current MA rate factor
Patients	CCM / mo	CCM / yr	APCM / mo	APCM / yr

Care management margin only — the full-service RPM margin above is additional. The two care management columns are alternatives, never a sum.

Before anyone acts on this

Seven things have to be true, and we do not yet know that they are

This model is built on system data and published fee schedules. Each item below replaces an assumption with a fact, and several of them can move the numbers materially in either direction. This list is the agenda for the next conversation.

MA remittance dataWhat do your Medicare Advantage plans actually pay on 99445, 99454, 99457 and 99458? This sets the MA rate factor, and the MA rate factor drives every dollar on this page.
Claims confirmationWere the units in the table above actually submitted as claims, and what was paid? Reconciling CoachCare-generated units to your remittance is the difference between a modeled baseline and a real one.
APCM and CCM coverage, plan by planConfirm that G0556–G0558 and 99490 / 99439 are separately payable, and at what rate. Some MA plans run their own care management programs and will not pay these to the practice.
Actual eligible panel sizeThe 600-patient panel is a placeholder. CCM requires 2 or more chronic conditions, so the CCM-eligible count will be smaller than the APCM-eligible count — which narrows the CCM advantage shown above.
Time segregation in the platformConfirm that CCM and RPM management minutes are logged separately and defensibly. If they are not, CCM layered on RPM is a compliance exposure rather than a revenue opportunity.
MIPS readinessPractices billing APCM must report the Value in Primary Care MIPS Value Pathway. Confirm the practice can meet it before the APCM path is chosen.
Period labelsConfirm which calendar months P1 through P7 represent, so trend and seasonality can be read correctly.

One more input, from your side. The model carries practice staff cost at zero in both scenarios — enrollment, device support and monitoring effort that never became a billable unit. That is real time being spent today. Supplying an honest monthly hours estimate makes the current-state number more accurate and, in all likelihood, strengthens rather than weakens the case for moving.

Assumptions and caveats

Everything behind the numbers, in full

Nothing here is hidden behind a toggle. If a figure on this page matters to a decision, the input that produced it is on this list.

Required disclosures

Units shown are CoachCare-system generated billable units. It is not confirmed that these were submitted as claims or that they were paid.
All figures are illustrative and modeled — not a proposal, guarantee, quotation, or offer of terms. This is not billing, coding, or legal advice.
Rates shown are Medicare fee-for-service non-facility amounts for Novitas Solutions 12302 / Locality 99 (Rest of Maryland), CY2026. The enrolled cohort is Medicare Advantage; actual contracted rates vary by plan and may be materially lower.
The 600-patient care management panel is a placeholder pending the practice’s actual eligible panel count.
CCM and APCM cannot be billed for the same patient in the same month. The two paths shown on this page are alternatives and must never be summed.
CCM and RPM treatment management time cannot be double-counted. The 20 minutes supporting 99490 must be distinct from the 20 minutes supporting 99457.

Practice and population

Practice — Primary Care Associates of Hagerstown, Hagerstown, MD 21740.
Rate basis — Novitas Solutions carrier 12302, Locality 99 (Rest of Maryland), CY2026 Physician Fee Schedule, non-facility.
Enrolled RPM patients — 200, practice-stated enrolled census billed monthly.
Payer mix of the enrolled cohort — Medicare Advantage.
MA rate factor — modeled at 100% of Medicare fee-for-service unless changed on the slider above. This is an assumption pending remittance data, not a finding.
Current fees — $12.50 platform + $12.50 device = $25.00 per enrolled patient per month.

Rates and benchmarks MA-adjusted column follows the slider

Code	Description	Benchmark	FFS rate	MA-adjusted	Service fee

RPM benchmarks are billable units generated per enrolled patient per month at CoachCare full service. APCM shares are the illustrative tier mix — validate against the panel’s actual risk profile; Tier 3 requires QMB status plus 2 or more chronic conditions. The 99490 benchmark is the share of enrolled patients generating a first 20-minute unit each month; the 99439 benchmark is average additional 20-minute increments per patient per month. 99453 is benchmarked low because setup is a one-time code on an already-enrolled census, not a recurring monthly unit.

Collections

Denial rate — 2.5%.
Coinsurance — 20% of allowed, with 25% of that coinsurance treated as bad debt. Verify against each MA plan’s cost-share design.
Net collection factor — 92.625%, applied to every allowed amount. (97.5% × 95% = 92.625%.)
Practice staff cost — carried at $0 per month in both scenarios. Non-billable program administration hours are a practice-supplied input left at zero so the current-state margin is not overstated.

Program rules reflected in this model

APCM requires an initiating visit and consent for new patients, or any patient not seen by the billing practitioner within three years. Thirteen service elements must be continuously available, including 24/7 access to a care team member with real-time record access. Practices billing APCM must report the Value in Primary Care MIPS Value Pathway.
CCM requires at least 20 minutes of documented clinical staff time per calendar month, patient consent, an initiating visit for new patients or any not seen within the prior 12 months, and 2 or more chronic conditions expected to last at least 12 months or until death.
Exclusivity — CCM may not be billed in the same month as APCM, PCM, TCM (99495–99496), ESRD services (90951–90970), or home health / hospice supervision (G0181, G0182) for the same patient. RPM stacks with either care management path.
99445 and 99454 pay identically at this locality ($52.70). The adherence mix between them matters clinically but carries no revenue difference; no upside is claimed from shifting patients between them.