A scalable, profitable remote care service line for Eagle’s Landing Diabetes & Endocrinology: the chronic care management program you already run, billed for nine in ten enrolled patients every month, plus remote monitoring for the Medicare panel, billed under your own NPIs and run by a CoachCare care team inside eClinicalWorks
Eagle’s Landing already did the hard part of chronic care management: about 650 patients have consented and enrolled. Four things make this the year to get paid for all of them, and each one lands in the weeks between a patient’s visits.
Eagle’s Landing Diabetes & Endocrinology has treated diabetes, thyroid and hormone disorders in Stockbridge since 2003. A board-certified endocrinologist and two family nurse practitioners see patients in one office off Eagles Landing Parkway, with an in-house lab, thyroid and carotid ultrasound, ultrasound-guided biopsy, continuous glucose monitoring and insulin pump care. Their traditional-Medicare patients average 71 years old; seven in ten have diabetes and at least three in four have hypertension. The practice bills inside an Enhanced-track Medicare Shared Savings Program ACO and already runs chronic care management for about 650 patients.
An older, higher-risk Medicare panel, average age 71, in which diabetes is the rule and hypertension, high cholesterol and kidney disease usually come with it.
72% of the practice’s traditional-Medicare patients have diabetes, many on insulin or a sensor. Control is decided by the weeks between quarterly visits: doses, lows, missed refills and the A1c that comes back high.
CMS caps the published figure at 75%, and both hypertension and high cholesterol hit that cap. Two or more chronic conditions is the norm here, which is the patient chronic care management was written for.
49% have chronic kidney disease, 25% ischemic heart disease and 17% heart failure. Home blood pressure and weight are how the care team sees those patients slipping before an admission.
Each step below added a capability. Click through the years. The next step makes the care-management program pay for every patient it already carries.
Each part of Eagle’s Landing touches a patient at one moment: a follow-up visit, a lab draw, a sensor download, an ultrasound. A remote care service line connects them, so a patient who leaves one visit is still being watched until the next. Select any part of the practice to see what changes.
Eagle’s Landing’s clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program at 165 patients per care manager. Everything runs through the eClinicalWorks system the practice already uses, from the first flag on a chart to the claim at month end.
The program starts with the patients already enrolled and then the rest of the panel. eClinicalWorks already holds the diagnoses, A1c results, blood pressures and medications. Patients with uncontrolled diabetes, hypertension, kidney disease or several chronic conditions are flagged using criteria the practice’s clinicians set, and enrolled patients who have not been reached this month are flagged before the month closes.
Example criteria. The practice’s clinicians set and own the flag logic for each condition.
The patients already enrolled move first, in three monthly waves, each to a named CoachCare care manager. New patients then enter at an office visit. Either way they land in the same monthly loop: office visits, care management and home readings, each one informing the next.
The enrolled list and care plans are read from eClinicalWorks. Consent is already on file with the practice; nothing is re-signed.
About a third of patients a month move to a named care manager, highest-risk first, with a welcome call from their new care manager.
99490A caseload of 165 leaves time to reach each patient and log the time against the care plan before the month closes.
99490 · 99439About 585 of the 650 enrolled patients bill every month.
A1c 8.9% and BP 158/94 on three agents. The clinician places the remote care order during the follow-up visit.
A cellular cuff at home, a welcome call by phone, and how to take a reading that counts.
99453Home averages drive blood-pressure changes month to month; the CCM call covers insulin, lows and labs due.
99454 · 99457 · 99490Office visits ↻ care management ↻ home readings.
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.
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, or a report of repeated lows, goes to the clinician the practice designates, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath, stroke signs or a severe low with confusion 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 creates claims in eClinicalWorks 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 an Eagle’s Landing remote care service line: the 650 patients already in chronic care management, run by CoachCare, plus new chronic care management and remote monitoring for the rest of the Medicare panel, priced at Atlanta-area CY2026 Medicare rates with every patient priced at the Medicare amount.
Four follow-up visits a year leave 361 days with no blood-pressure 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, and the monthly care-management call fills in the rest.
At least three in four of the practice’s patients carry hypertension with their diabetes, and in diabetes blood pressure decides the kidney and heart outcomes as much as glucose does. 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.
Eagle’s Landing’s clinicians take part in an Enhanced-track Medicare Shared Savings Program ACO, which is scored on a fixed set of quality measures. The diabetes measure leads the list, and monthly care management moves it. Select a measure to see how.
Hearing from every enrolled patient every month tells the practice who needs to be seen now, not only who is next on the schedule. Patients surface from their home data and their calls, not only when they come in sicker.
Today about 30% of the enrolled patients bill in a month, and the outside care-management service keeps half of what they collect. With a CoachCare care manager for every 165 patients, nine in ten bill every month. Same patients, same codes, same rates. Move the sliders to put in the practice’s own numbers.
Both columns use the same collections per billed patient-month, $121.57, at Atlanta-area CY2026 Medicare rates (99490 with the 99439 add-on) after denials and coinsurance. CoachCare fees are per enrolled patient and per completed 20 minutes, so they rise only when the practice is paid. Today’s column leaves out the cost of the practice’s own staff time on the program; with CoachCare that time is zero.
Every code the service line bills, at CY2026 Medicare rates for the Atlanta area. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Georgia locality 01, Atlanta (Palmetto GBA, carrier 10212). Only one device code (99454 or 99445) and one first-tier management code (99457 or 99470) bill per patient per month. About 62% of Henry County’s Medicare beneficiaries 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.
Eagle’s Landing can move the chronic care management program it runs today to CoachCare and stop there, or move it and add new enrollment and remote monitoring for the rest of the Medicare panel. Either way the program is net-positive from the first month. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $1,222,550 | $1,439,006 | $2,661,557 |
| CoachCare cost (program and eClinicalWorks fees) | $711,899 | $823,525 | $1,535,423 |
| Net to Eagle’s Landing after fees | $510,652 | $615,481 | $1,126,133 |
| Margin to Eagle’s Landing | 41.8% | 42.8% | 42.3% |
| By program, net reimbursement: today’s chronic care management patients $1,394,472 · new chronic care management $485,236 · remote monitoring $781,849. Net-positive from month 1. 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 practice’s own Medicare chart count and its current enrolled count are the first two things to plug in.
CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. That caseload is what leaves time to reach every enrolled patient before the month closes. Drag the slider to see the team grow with the census.
The practice’s nurses and medical assistants already carry prior authorizations, refills and a busy phone line. The monthly calls, the documentation and the claim preparation move to CoachCare, and the staff time the current program takes comes back to the office.
Monthly calls, monitoring and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. Eagle’s Landing would otherwise need to recruit and keep them.
The enrollment specialist working in the office and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system Eagle’s Landing 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 chronic care management and remote monitoring can take on the next programs the panel qualifies for, without a second hiring plan.
Patients whose care centers on one complex condition, such as hard-to-control thyroid disease or osteoporosis on treatment, qualify for principal care management in place of CCM. The same care managers can run it.
About 20% of the practice’s traditional-Medicare patients carry anxiety and 17% depression. Behavioral health integration fits the same care-manager calls and the same chart.
A cellular scale and a monthly call fit the practice’s weight-management program, with trends and side effects in the chart between visits.
Six reasons this partnership fits Eagle’s Landing specifically, not remote care in general.
A caseload of 165 per care manager is what turns an enrolled list into a billed one: nine in ten of the 650 patients reach 20 minutes every month, against about 30% today.
Built on eClinicalWorks’ own workflows. Call time, readings, care plans and claims live in the chart the practice already works in.
Enrollment, devices, business-hours alert triage, the monthly calls and billing preparation are on CoachCare’s payroll. Fees are per enrolled patient and per completed service, with no capital outlay.
Eagle’s Landing’s clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under the practice’s own billing entity and NPIs.
The practice’s traditional-Medicare patients average 71. 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 review a month of the current program’s billed-versus-enrolled report, confirm the Medicare chart count by payer, scope the eClinicalWorks integration and the hand-off of the current enrolled patients, and agree how the first 90 days run before anyone is moved.
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