A scalable, profitable remote care service line for Boice-Willis Clinic: remote monitoring and chronic care management for the heart failure and kidney disease patients your five primary care sites already know, billed under your own NPIs and run by a CoachCare care team inside eClinicalWorks
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.
Boice-Willis Clinic has practiced medicine in Rocky Mount for more than a century and is still a physician-led group. Thirty-one adult primary care clinicians work across five sites in Rocky Mount, Nashville and Spring Hope, with nephrology, endocrinology, pulmonology and gastroenterology in the same group, a CLIA-certified lab and a diabetes education center, all on one eClinicalWorks system. Their traditional-Medicare patients average 75 years old and carry a CMS risk score of 1.46; three in four have hypertension and two in five have diabetes. The group bills inside an Enhanced-track Medicare Shared Savings Program ACO, completes about 3,600 annual wellness visits a year, and already runs transitional care and chronic care management.
An older Medicare panel, average age 75, in which hypertension and high cholesterol are the norm and diabetes and kidney disease each touch about two in five patients.
75% of the group’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.
41% of the group’s traditional-Medicare patients have diabetes and 44% chronic kidney disease, usually alongside hypertension. Two or more chronic conditions is the patient chronic care management was written for.
33% have ischemic heart disease, 20% atrial fibrillation, 22% heart failure and 19% COPD. Pulmonology and nephrology work in the same group; daily weight, blood pressure and oxygen readings fill in the months between visits.
Each step below added offices, clinicians or capability. Click through the years. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of Boice-Willis touches a patient at one moment: an office visit, a walk-in visit, a wellness visit, a lab draw, 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.
Boice-Willis’ clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the eClinicalWorks system every site already uses, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. eClinicalWorks already holds the diagnoses, vitals, labs and medications. Patients with heart failure or chronic kidney disease are flagged, highest risk first, using criteria the group’s clinicians set, so the right patients surface at a chronic-care visit, at an annual wellness visit, or on an outreach list.
Example criteria. The group’s clinicians set and own the flag logic for each condition.
Heart failure and kidney patients enter at an office 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.
Select a patient to open the example; select it again to close it.
Heart failure, weight up 3 lb since the last visit and BP 146/88 on two agents. The clinician places the remote care order before checkout.
Cellular scale and BP cuff at home, a welcome call by phone, and a morning routine: weigh, then take a reading.
99453Weight catches fluid early; home BP averages guide heart-failure medication changes between visits.
99454 · 99457Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Scale and cuff 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.
CKD stage 3b, eGFR down from 44 to 38, office BP 154/90 on two agents. The clinician orders home BP monitoring at the visit.
Cellular BP cuff at home and a welcome call on how to take a reading that counts.
99453Home averages drive dose changes; the kidney labs that follow each change are drawn at the group’s own lab.
99454 · 99457Office 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 each site 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 Boice-Willis remote care service line: remote monitoring and chronic care management for the group’s heart failure and kidney disease patients, on traditional Medicare and Medicare Advantage, priced at North Carolina’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.
Most heart failure and kidney patients also carry hypertension, and it is the condition 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.
Boice-Willis’ clinicians take part in an Enhanced-track Medicare Shared Savings Program ACO, which is scored on a fixed set of quality measures. 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.
Sixteen of the group’s clinicians already bill transitional care after hospital stays. The next 30 days decide whether a patient comes back, and 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 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 North Carolina. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, North Carolina locality 00 (Palmetto GBA, MAC 11502). 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 63% of Medicare beneficiaries in Nash and Edgecombe counties are in Medicare Advantage. Those plans cover these Part B services and pay them on each plan’s own contract terms; the forecast prices every patient at the Medicare amount.
Boice-Willis can hand CoachCare the remote monitoring and leave chronic care management with its own care coordinators, 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 | 990 | 2,255 | 2,255 |
| Contribution margin | $258,857 | $1,109,509 | $1,368,366 |
| Contribution margin runs −$5,564 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. The group’s own Medicare chart count is the first thing to plug in. Neither program reaches every eligible heart failure and kidney patient inside two years (remote monitoring is at about 92% of its ceiling by month 24), so referral volume, onboarding pace and panel size all move the answer.
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.
The group’s physicians, nurse practitioners, physician assistants and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. Boice-Willis would otherwise need to recruit and keep them.
The enrollment specialist working in the sites and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system Boice-Willis 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 remote monitoring and chronic care management can take on the next programs the group’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. Boice-Willis can bill it today, and its Shared Savings Program participation fits the accountable-care model APCM was built around. For traditional-Medicare patients, whether it belongs beside the group’s own care management is a decision to make together.
About one in four traditional-Medicare patients carries depression, and the group screened about ~3,600 for it in CY2024, and a psychiatric-mental-health nurse practitioner is on its provider roster. Behavioral health integration fits the same care-manager calls and the same chart.
Sixteen of the group’s clinicians already bill transitional care. The same care team can make the two-business-day call after every discharge, so more of them qualify, billed by the group.
Boice-Willis’ clinicians belong to a two-sided Shared Savings Program ACO. Since 2025 its patients are assigned at the end of each year, based on where they got most of their primary care, so most of the group’s traditional-Medicare patients sit inside its benchmark. Every remote monitoring claim for one of those patients is Part B spending the ACO is measured on. The spending holds up where it prevents admissions worth more than it costs. In this panel, that means heart failure and kidney disease, the patients this service line enrolls. At Boice-Willis they are more than half the panel.
The same remote monitoring claim lands in two different places depending on how the patient is covered. Medicare Advantage claims are practice revenue and nothing else. Traditional-Medicare claims for an assigned patient are practice revenue that also counts against the ACO’s spending target. In Nash and Edgecombe counties, most of the panel is on Medicare Advantage.
Medicare’s share of a year of remote monitoring is about $941 per patient. One avoided hospital stay is worth about $12,876, the ACO’s own average for an acute admission. Whether the program pays its way depends on how often the patient would have been admitted.
| Assigned traditional-Medicare patients | Patients | Admissions per 100 a year | Avoided per 100 at a 30% reduction | Net to the ACO per patient-year | Reduction needed to break even |
|---|---|---|---|---|---|
| Heart failure | 1,100 | 40 | 12 | +$604 | 18% |
| Chronic kidney disease, without heart failure | 1,600 | 44.5 | 13.4 | +$778 | 16% |
Heart failure and kidney disease patients among the group’s estimated assigned panel. Prevalence from CMS CY2024 claims for the group’s adult primary care clinicians; admission rates from the USRDS 2025 Annual Data Report (kidney disease, 44.5 per 100 at stage 3; 19.5 per 100 without it) and a conservative 40 per 100 for heart failure. The 30% reduction is close to the 29% cut in heart failure hospitalizations that pooled telemonitoring trials report.
At month 24 the forecast has 1,961 patients on remote monitoring, every one with heart failure or kidney disease. About 600 of them are assigned to the ACO. Choose the reduction in admissions to see where the ledger holds.
The service line enrolls the same patients whether Medicare pays through Part B or a Medicare Advantage plan. These are the patients most likely to be admitted, where a prevented stay is worth more than the program costs.
Daily weight and blood pressure for about 600 assigned patients at month 24. The program pays back to the ACO at a 18% reduction in heart failure admissions and 16% in kidney disease. Chronic care management for these patients stays with the group’s own care coordinators, who already run it.
The same patients and the same daily readings, plus monthly care management. Every claim is practice revenue and none of it touches the ACO’s benchmark. About 1,200 on remote monitoring at month 24.
In a two-sided ACO the quality score does two jobs. Meeting CMS’s standard keeps the ACO at the full 75% sharing rate. It also holds the share of any loss at the 40% floor, where a miss can push it as high as 75%. The ACO scored 87.5 in PY2024, up from 83.5, against a PY2026 standard of 73.85. The measures behind that score are the ones monthly remote care moves.
| Measure | PY2023 | PY2024 | Better than | How the program moves it |
|---|---|---|---|---|
| Q134 Depression screening and follow-up | 73.8 | 75.7 | 23% of ACOs | The measure with the most room. PHQ-2, then PHQ-9, on the monthly care-management call, with a positive screen routed to the patient’s clinician for follow-up. |
| Q001 Diabetes, A1c above 9% (lower is better) | 6.2 | 9.2 | 38% of ACOs | The one measure that slipped. Care-management calls keep A1c tests and medication changes on schedule. |
| Q236 Controlling high blood pressure | 80.5 | 83.2 | 68% of ACOs | Home readings on 16+ days a month and titration between visits. CMS counts readings from a device that transmits them to the clinician. |
| Q479 Hospital-wide 30-day readmission | 15.4% | 14.7% | 69% of ACOs | A call within two business days and devices home before the follow-up visit. |
CMS Shared Savings Program Financial and Quality Results, PY2023 and PY2024; ranks against all 476 ACOs scored in PY2024. Q479 is a rate. The claims-based measure for admissions among patients with several chronic conditions (Q484) was not published for the ACO in PY2024.
About 63% of Medicare beneficiaries in Nash and Edgecombe counties are on Medicare Advantage. Their plans are rated on a parallel set of measures, and plans pay practices for closing those gaps. For a heart failure or kidney patient on a plan, the monthly program does the same work for the plan’s Star Rating that it does for the ACO’s quality score.
| Star Ratings measure | Weight | How the program moves it |
|---|---|---|
| Controlling blood pressure | Triple | Home readings sent from a cellular cuff count toward the measure, so a controlled month at home closes the gap without waiting for an office reading. |
| Plan all-cause readmissions | Triple | The same post-discharge cadence as Q479: a call within two business days, daily weight and BP from day two, and a visit inside the transitional-care window. |
| Blood sugar controlled, patients with diabetes | Triple | Monthly care management keeps the A1c test and the medication change after it on schedule. |
| Medication adherence, blood pressure and diabetes drugs | Triple | Missed doses show up in the home readings, and the care-management call reviews refills before the patient runs out. |
| Transitions of care | Single | Medication reconciliation and patient engagement after discharge, documented in eClinicalWorks by the care team. |
CMS Medicare Part C and D Star Ratings, 2026 measure set and weights. Medicare Advantage penetration from CMS State/County Penetration, October 2026.
ACCESS is a ten-year CMS model, launched in July 2026, for technology-supported chronic care that is measured by results: blood pressure, A1c, cholesterol, weight and kidney labs. An approved ACCESS organization enrolls the patient and delivers the care between visits. Boice-Willis stays the patient’s doctor and bills Medicare for reviewing their progress. For a group inside an ACO, it covers the traditional-Medicare patients the last two chapters leave out: those without heart failure or kidney disease.
| Remote monitoring (fee-for-service) | ACCESS (CMS model) | |
|---|---|---|
| What the practice bills | RPM codes each month, under the group’s NPIs | Co-management codes for each review of a care update |
| How patients join | An office visit and a clinician’s order | Patient consent; no referral or order needed |
| Patient cost | 20% coinsurance each month | $0 |
| What is measured | Days of readings and minutes of care | BP, A1c, LDL, weight and kidney labs, against targets |
| Effect on the ACO | Every claim counts as spending from the first month | Outcome payments expected to have no effect on benchmark and spending calculations in 2026 and 2027; counted from 2028 |
| Coverage | Traditional Medicare and Medicare Advantage | Traditional Medicare only, for now |
About 2,400 of the group’s roughly 5,600 traditional-Medicare patients have neither heart failure nor kidney disease. Their conditions are the ones ACCESS pays to improve, and each maps to a track.
Share of traditional-Medicare patients with hypertension; 75% or more have high cholesterol. Scored on blood pressure, LDL and weight.
Share with diabetes; 33% have ischemic heart disease. Scored on A1c, blood pressure and LDL. Stage 3 kidney disease also qualifies, but under this plan those patients are on remote monitoring.
Share with arthritis, the largest source of chronic joint pain on the panel. Scored on patient-reported pain and function.
Share with depression. A second track for the same patient, scored on PHQ-9 and GAD-7, with its own co-management payments to the practice.
CMS CY2024 claims for the group’s adult primary care clinicians, share of traditional-Medicare patients with each condition. Conditions overlap, and CMS caps published prevalence at 75%, so hypertension and high cholesterol are floors.
Medicare pays the practice $30 for each review of an ACCESS care update, up to three a year, plus $10 once at onboarding, per patient per track. The review takes at least five minutes and one care-coordination step, such as a medication change or an updated problem list. There is no patient cost-sharing on these codes.
Six reasons this partnership fits Boice-Willis specifically, not remote care in general.
Annual wellness visits, its own lab and diabetes education center, a walk-in clinic, transitional care after hospital stays and an in-house chronic care management program are already part of the week. CoachCare adds daily readings and the capacity to reach the rest of the panel, beside the coordinators already doing the work.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible at every site.
CoachCare’s care managers carry the caseload at 165 patients each. Enrollment, devices, business-hours alert triage and billing preparation are on CoachCare’s payroll, with no capital outlay.
Boice-Willis’ clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under the group’s own billing entity and NPIs.
The group’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 Boice-Willis’ Medicare chart count by payer and how its Medicare Advantage plans pay for care-management codes, map how CoachCare sits beside the care coordinators who run chronic care management today, scope the eClinicalWorks integration, and set the order the five primary care sites go live before the first patient enrolls.
Download the Full Executive Report (PDF)