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.
Three things converge in 2026: Medicare's remote-care codes now cover the exact windows nephrology needs, downstate-New York reimbursement makes the economics unusually strong, and the clinical case — catching decline before it becomes a crash start — has never been clearer.
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, turning 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.
Not a gadget program bolted onto the clinic — 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 |
Illustrative magnitudes. The Value Analysis below uses Medicare MAC-locality rates auto-resolved for ZIP 11714 (NY downstate). Verify against the current CY Physician Fee Schedule.
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%). Illustrative, modeled — verify against practice data.
Figures are illustrative, modeled — verify against practice data. Values are rounded to the nearest dollar, so row and column sums may differ by $1. 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. Illustrative — the actual funnel is set in protocol design.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers committed to remote care excellence.
Successful program implementations.
Care plan coding and billing generating over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Every number on this page traces to the CoachCare Value Analysis workbook or cited public data. The key assumptions: