A scalable, profitable remote care service line for Partners in Internal Medicine: remote monitoring and chronic care management for PIIM’s Medicare patients, built into eClinicalWorks, billed under PIIM’s own NPIs, and run by CoachCare’s care team under PIIM’s physicians
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.
Partners in Internal Medicine is an independent, physician-owned internal medicine practice in Canton that has cared for adults in western Wayne and Washtenaw counties for decades. Its traditional-Medicare patients average 75 years old, and about seven in ten have hypertension. PIIM already does the preventive work well: in CY2024 its clinicians billed annual wellness visits for about 1,160 traditional-Medicare patients and advance care planning for about 910. Monthly care between visits is the piece Medicare would not pay a Primary Care First practice for, and 2026 is the first year that rule is gone.
A Medicare panel averaging 75 years old, in which hypertension and high cholesterol are the norm and diabetes, heart disease and kidney disease are common.
69% of PIIM’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.
23% of these patients have diabetes and 20% chronic kidney disease, usually alongside hypertension. Two or more chronic conditions is the patient chronic care management was written for.
22% have ischemic heart disease, 15% atrial fibrillation, 11% heart failure and 10% COPD. PIIM’s internists manage them in the office; daily weight, blood pressure and oxygen saturation fill in the months between.
Each step below added clinicians, capability or a new way of being paid. Click through the steps. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of PIIM touches a patient at one moment: an internist visit, a wellness visit, an advance care planning conversation, an in-office A1c, a referral, 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.
PIIM’s physicians set the protocols and own every clinical decision. CoachCare’s care team does the monthly work: enrollment, devices, monitoring, outreach and claim preparation. The program runs through PIIM’s eClinicalWorks chart, from the first flag on a patient’s record to the claim at month end.
The program starts with the panel, not a referral pad. eClinicalWorks holds the diagnoses, vitals, labs and medications. Patients with uncontrolled hypertension, diabetes, kidney disease or several chronic conditions are flagged using criteria PIIM’s physicians set, so the right patients surface at a chronic-care visit, at an annual wellness visit, or on an outreach list.
Example criteria. PIIM’s physicians 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 PIIM 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 PIIM remote care service line: remote monitoring and chronic care management across the Medicare panel, priced at the Detroit locality’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 PIIM’s Medicare 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.
PIIM is scored on a fixed set of quality measures through the Medicare Shared Savings Program measure set, and shared savings depend on them. 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.
The 30 days after a hospital stay decide whether a patient comes back, and under an accountable care arrangement every readmission counts against the practice. 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 to the patient’s own PIIM internist 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 the Detroit locality. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Michigan locality 01, Detroit (MAC 08202). Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill for a patient in a given month. About 62% of Medicare beneficiaries in Wayne and Washtenaw counties are in Medicare Advantage, so more than half of this panel is likely paid under Medicare Advantage contracts. 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.
PIIM can start with remote monitoring alone, 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 |
|---|---|---|---|
| Unique patients, end of period | 468 | 706 | 706 |
| Contribution margin | $145,719 | $547,267 | $692,986 |
| Contribution margin runs −$6,096 in month 1 while the program ramps; positive from month 2. 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. PIIM’s own Medicare chart count is the first thing to plug in: enrollment pace sets the first year, and the size of the panel in scope sets the census once both programs reach their ceilings in the second year.
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.
PIIM’s physicians, nurse practitioner and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare’s care team.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. PIIM would otherwise need to recruit and keep them.
The enrollment specialist working in PIIM’s office and device logistics are CoachCare’s expense.
Direct integration with PIIM’s eClinicalWorks system, using its built-in workflows, so the program lives in the chart the physicians already use. 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 PIIM’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. It is the Medicare code closest to the monthly amount Primary Care First paid. It is not in this forecast; it is an option to weigh against CCM once PIIM’s accountable care contracts and payer mix are mapped.
About one in nine of PIIM’s traditional-Medicare patients carries a depression diagnosis. Behavioral health integration fits the same care-manager calls and the same chart.
CY2024 claims show no transitional care management at a volume CMS reports. The same care team can make the two-business-day call after every discharge, so the visit that follows qualifies, billed by PIIM.
Six reasons this partnership fits PIIM specifically, not remote care in general.
Annual wellness visits, advance care planning, in-office A1c testing and a medical home’s care coordination are already part of the week. CoachCare adds the monthly contact Primary Care First never paid for separately; it does not replace the people who do the rest.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in PIIM’s chart, so physicians never open a second system.
CoachCare’s care managers carry the caseload at 165 patients each, with enrollment, devices, business-hours alert triage and billing preparation on CoachCare’s payroll. PIIM adds a service line without adding a payroll line.
PIIM’s physicians set the protocols, sign the care plans and make every clinical decision. Claims go out under PIIM’s own billing entity and NPIs.
PIIM’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 PIIM’s Medicare chart count by payer, check how each Medicare Advantage contract covers the care-management codes, agree how the program fits PIIM’s accountable care work, and scope the eClinicalWorks integration, before the first patient enrolls.
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