Kidney disease doesn't progress in the exam room. It progresses in the 90 days between nephrology visits. A CoachCare Remote Care Service Line gives Long Island Kidney Associates continuous, billable visibility into CKD stages 3b–5, resistant hypertension, diabetic kidney disease, and the transition months around dialysis — without adding a single hire.
Long Island Kidney Associates already rounds where kidney patients get sick, get discharged, and get dialyzed — across Nassau and Suffolk. What the practice doesn't have yet is a way to see those patients, and bill for managing them, in the weeks between encounters. That's the whitespace this strategy fills.
A single-specialty, physician-owned group serving Nassau and Suffolk from Bethpage and Babylon — independent, and positioned to stay that way.
Standing rounding affiliations across seven SNFs — exactly where the highest-risk, most transition-prone kidney patients concentrate.
Privileges spanning Good Samaritan University Hospital, South Shore University Hospital, Plainview Hospital, and St. Joseph Hospital — the discharge points that feed the practice's panel.
In-center rounding across eight affiliated dialysis units in the service area — the practice already owns the clinical relationship across the full arc of kidney care.
That rounding footprint is the raw material of a remote care program: every SNF stay and hospital discharge is an enrollment moment the practice already touches. What's missing is the service line itself — no remote monitoring or care-management program is marketed by the practice today.
In 2026, Medicare's remote-care codes cover the exact windows nephrology needs, downstate-New York reimbursement makes the economics unusually strong, and continuous monitoring catches decline before it becomes a crash start.
New CY2026 codes cover 2–15-day device-supply windows (99445) and the first 10 minutes of management (99470) — removing the 16-day floor that previously blocked episodic monitoring. Post-discharge, post-AKI, and medication-titration windows are now cleanly billable alongside the established monthly RPM codes.
An unplanned, in-hospital dialysis start is the most expensive, most traumatic way to begin renal replacement — and it usually forecloses home modality and access-first options. Daily BP and weight signal from the CKD 3b–5 panel is the earliest warning system a practice can own. It turns urgent starts into planned ones.
The model behind this page uses Medicare rates auto-resolved for the practice's own locality (ZIP 11714, NY downstate) — for example, ~$62/month for device supply and ~$78/month for the first PCM management code. High-reimbursement geography means the program clears healthy margins at standard pricing, with no value-based contract required.
A named service line with its own P&L, built on the two care-management programs Medicare designed for a specialty practice like this one, with a third attached to the rounding work the physicians already do.
| Service | Codes | ~CY2026 Magnitude | Nephrology Use |
|---|---|---|---|
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$62/mo | BP + weight monitoring; 99445 unlocks 2–15-day post-discharge and titration windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$60 + add'l units | Monthly review, medication titration, escalation to the nephrologist |
| Principal Care Management | 99426 · 99427 | ~$78 + add'l units | CKD as the single dominant condition, managed ≥3 months |
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | SNF and hospital discharges on existing rounding — upside, not in the forecast |
The Value Analysis below uses Medicare MAC-locality rates auto-resolved for ZIP 11714 (NY downstate).
The same infrastructure — enrollment, devices, alerts, documentation, billing — earns its keep four different ways. Only the first is in the forecast; the rest compound on top.
The program runs on CoachCare's own platform from the start: a secure clinician portal for the care team, cellular devices that transmit the day they're unboxed, 24/7 alert monitoring, and billing-ready documentation generated automatically every month. Nothing about launch waits on an IT project.
Physicians and staff review trends, alerts, and monthly summaries in one secure web portal — no new hardware, no software installation, no dependence on any practice system.
BP cuffs and scales ship pre-configured and transmit over cellular — no patient Wi-Fi, smartphone, or app setup required. Built for a Medicare-age panel.
Every managed patient generates complete, audit-ready claims documentation each month — time logs, readings, and care actions mapped to the correct codes automatically.
CoachCare also maintains direct integrations across the major ambulatory EMR platforms — vitals into the chart, enrollment status, and claims data flowing automatically. Discovery item #1 is confirming the practice's current EMR vendor so integration can be scoped precisely; the forecast below already includes conservative integration fees, and the program launches on the portal either way.
A 24-month forecast for the RPM + PCM core: an estimated ~1,350-patient Medicare panel across 5 nephrologists, one CoachCare-funded on-site enrollment specialist, and Medicare rates for the practice's own locality (ZIP 11714). TCM revenue, avoided-hospitalization savings, and referral effects are not in these numbers — they are upside on top.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $267,929 | $478,761 | $746,691 |
| PCM net reimbursement | $112,253 | $350,739 | $462,992 |
| Total net reimbursement | $380,183 | $829,500 | $1,209,683 |
| CoachCare program fees | $206,997 | $458,332 | $665,329 |
| Ancillary & one-time fees | $16,425 | $12,434 | $28,859 |
| Practice margin (after all fees) | $156,761 | $358,734 | $515,495 |
| Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value that is never subtracted from the practice margin above. | |||
24-month practice margin: 42.6% of net reimbursement (Year 1 41.2%, Year 2 43.2%).
Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous BP-and-weight picture of the CKD and hypertension panels between visits.
≈ $656K in avoided acute cost at $15K per admission — and fewer crash starts.
9,312 care-team hours of monitoring, outreach, and documentation handled by the service line.
CoachCare operates as the service line's engine — enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation — while Long Island Kidney Associates' physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new practice headcount: the on-site enrollment specialist is staffed at CoachCare's expense, and the practice's role is clinical oversight it already performs.
Named physician owner and P&L; billing configuration for the locality; protocol sign-off for CKD, hypertension, and diabetic kidney disease pathways; EMR vendor confirmation and integration scoping (discovery item #1); panel validation against practice chart counts.
Bethpage and Babylon clinics referring; the on-site enrollment specialist working the CKD 3b–5 and resistant-hypertension panels; first billable enrollments by day 45; devices transmitting from week one of enrollment.
TCM layered onto SNF and hospital discharges the physicians already round on — the non-modeled upside lever — while RPM census reaches its modeled ceiling of 355 active enrollments by month 11.
PCM census still climbing — it reaches its 344 ceiling only in month 23, so PCM carries growth through year two; quarterly reviews of enrollment acceptance, crash-start saves, and referring-PCP data flow; expansion levers (panel growth, additional enrollment staffing) sized from real program data.
The Bethpage office — the practice's home base on Hempstead Turnpike — is the natural launch site: the largest concentration of the CKD panel, the on-site enrollment specialist's desk, and same-building access to the physicians who will govern the protocols. Babylon follows in the second wave with zero re-implementation.
A Bethpage-first launch lets one office's physicians and staff shake out the referral workflow, and produces the internal evidence — census, capture rate, revenue per patient-month, avoided-admission signal — that makes every subsequent decision a data decision, not a leap.
| Milestone | Target |
|---|---|
| Protocol sign-off + billing configuration | Day 30 |
| EMR vendor confirmed, integration scoped | Day 30 |
| First billable enrollments | Day 30–45 |
| TCM rounding-attach workflow drafted | Day 60 |
| Active program enrollments by Day 90* | ~90 |
| Go / scale decision with full unit economics | Day 90 |
*The modeled months 1–3 census across both programs (18 → 48 → 90 active enrollments), concentrated at Bethpage during the first phase.
The service line described 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 platform.
Remote care programs implemented and running.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals and 4 million+ care actions recorded.
CMS's CY2027 Physician Fee Schedule proposed rule, published July 16, 2026, proposes to reprice remote physiologic monitoring. Here is what it reaches, what it leaves alone, and how the operating model behind this service line absorbs it.
CMS's remote-monitoring proposals sit in one code family: RPM. CCM, PCM, and TCM are not part of them. That distinction lands directly on this forecast — PCM carries $462,992 of the modeled $1,209,683 in 24-month net reimbursement, and the TCM touch at discharge is outside the proposal entirely. Neither is in scope.
The delivery model has more than one shape, and CoachCare is preparing each so the service line's economics hold wherever the rule settles. One unbundles the program into its parts — SaaS platform, device logistics, and program enablement — priced as components. Another engages CoachCare to run the staffing itself, an MSO-style arrangement in which the practice owns the clinical program and the billing while CoachCare carries the labor model. Neither requires re-architecting the service line described on this page.
Alongside the fee schedule, CMS's ACCESS Model pays remote care as a risk-based per-member-per-month arrangement rather than per code: recurring per-beneficiary payments, half of each one withheld and reconciled against outcome attainment. Cardiometabolic care is among its four clinical tracks. What earns under that structure — controlled pressures, titrated therapy, decompensations caught early — is what this service line is built to produce.
This forecast repriced code by code at CMS's CY2027 proposed values, at this practice's own MAC locality rather than national averages. Same enrollment, same phasing plan — only the rates move.
Both bars run on the same dollar scale, so the red slice is nearly the same width in each — the same dollars, measured against a larger base. The empty track on the top bar is the care-management revenue RPM alone does not include.
Repriced at this locality's own geographic adjusters. The RPM reductions fall almost entirely on practice expense, so the untouched work component carries more weight in some localities than others; the same repricing at national rates would be −8.8% on RPM. Of the $66,849, RPM accounts for $64,800 and the care-management arm for $2,049.
CY2026 versus CMS's published CY2027 proposed values, shown at national non-facility amounts so they can be read against CMS's own tables. This practice's locality-adjusted amounts differ; the repricing above uses the local figures.
| Code family | What CMS proposed | CY2026 | CY2027 proposed | Change |
|---|---|---|---|---|
| In scope — remote physiologic monitoring | ||||
| 99454 / 99445 · device supply | Practice expense recrosswalked | $52.11 | $41.38 | −21% |
| 99457 · management, first 20 min | Direct practice expense removed | $51.77 | $49.59 | −4% |
| 99458 · management, each addl 20 min | Direct practice expense removed | $41.42 | $40.39 | −2% |
| 99453 · setup and patient education | Crosswalked; one-time per patient | $21.71 | $20.03 | −8% |
| Not in scope — the codes the proposal does not reach | ||||
| 99424–99427 · PCM | No structural change proposed | $67.80 | $67.00 | −1% |
| 99495 / 99496 · TCM | Not addressed by the proposal | Outside the remote-monitoring provisions entirely | ||
National non-facility amounts; CY2027 values are CMS's own published proposals in Addendum B of CMS-1848-P. The care-management rows show the lead code in each family; every code in those families moves within about 4% in either direction, which is ordinary annual movement rather than a repricing. The RPM reductions are also phased — section 1848(c)(7) of the Act caps any one code's total-RVU reduction at 19% in a single year, and CMS publishes the affected codes, so CY2027 is a single-digit year for a typical program and the remainder arrives no earlier than CY2028.
Six reasons this partnership fits Long Island Kidney Associates specifically, not remote care in general.
CoachCare maintains direct bi-directional integrations across the major ambulatory EMR platforms: eligibility and orders leave the chart, and vitals, care documentation and claim-ready charges come back into it. Confirming which EMR the practice runs is the first discovery item, and the interface scope follows from that one answer.
Enrollment outreach, the care team, device logistics, 24/7 alert triage and billing preparation sit on CoachCare's payroll. The practice inherits a running RPM and PCM program at a 42.6% 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. Claims go out under Long Island Kidney Associates, P.C. and the NPIs the group already bills through. CoachCare supplies the staff, devices, platform and billing preparation under that governance.
No remote monitoring or care-management program is marketed by the practice today, so this is a first build, not a vendor swap. There is no incumbent contract to exit and no split census to reconcile. The service line starts from a clean sheet on the panel you already treat.
RPM and PCM run together for CKD, resistant hypertension and diabetic kidney disease, and they stack for the same patient in the same month. In-center rounding across the eight affiliated dialysis units and the discharge-to-RPM attach at every transition give one care-management spine several places to work.
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.