Prepared for Tri-City Cardiology · 2026 Strategy Review · Confidential — not for distribution
Cardiology Remote Care Service Line · Mesa, Arizona

A Scalable, Profitable Remote Care Service Line
for Tri-City Cardiology.

Roughly 73% of the practice's admissions land at 2-star hospitals, and nothing reimbursed follows the patient home. Medicare pays for that missing layer — TCM at discharge, then RPM, then PCM — and it is margin-positive before any value-based dollar. This is what that service line looks like across 29 physicians and 13 locations.

0
Unique Patients in Active Remote Care (Month 24)
$0
24-Month Net Reimbursement
$0
Net to Practice (After Fees)
0
Hospitalizations Avoided
$0
Avoided Acute Cost (Clinical Value)

A note on how patients are counted. Enrolled Patients are unique individuals — 5,779 at Month 24. Enrolled Services are total program enrollments — 7,017 at Month 24 — because roughly 70% of PCM enrollees also carry RPM, so those patients count once as a patient and twice as a service. Every chart and calculator below reports active program enrollments; the headline reports unique patients.

The Structural Exposure

Your Patients Discharge Into Hospitals You Don't Control

Tri-City's physicians hold privileges across two competing systems — deliberately, and to the practice's advantage. But the destination mix is not neutral. CMS Care Compare facility-affiliation data resolves five admitting hospitals for the group, and the three that take the large majority of admissions carry the lowest overall star ratings of the five.

Admitting HospitalSystemShareCMS Stars
Banner Desert Medical CenterBanner~34%★★
Banner Baywood Medical CenterBanner~26%★★
Banner Heart HospitalBanner~13%★★
Chandler Regional Medical CenterDignity / CommonSpirit★★★★
Mercy Gilbert Medical CenterDignity / CommonSpirit★★★★★
Three 2-star destinations~73%of admissions

Affiliations from the CMS Care Compare Facility Affiliation file; overall star ratings from the CMS Hospital General Information file (both queried July 2026). Admission-share percentages are third-party practice-affiliation data.

What It Means Operationally

Readmission risk that is measurable, concentrated — and clinically uncontrolled today.

A star rating is a composite, and readmissions are one of its heaviest components. When roughly three-quarters of a cardiology group's inpatient volume flows to facilities rated at the bottom of the CMS scale, the 30-day window after discharge is the practice's exposure, not the hospital's alone — the patient comes back to Tri-City's clinic, or doesn't come back at all.

Today there is no program watching that window. No post-discharge monitoring, no titration cadence, no daily weight or blood-pressure signal, no escalation path between the discharge summary and the next office visit. The heart-failure patient is told to track their own weight at home.

The modeled counter-position: a TCM-to-RPM handoff at discharge, layered into longitudinal PCM, produces 433 avoided hospitalizations over 24 months — roughly $6.49M of avoided acute cost. That value accrues to the patient, the payer, and the practice's referral reputation; it is shown here as clinical value, and is excluded from every revenue figure on this page.
Not a Naive Buyer

The Billable Layer Is Missing.
The Clinical Adoption Question Is Answered.

This is not a group that has to be convinced remote monitoring works. Tri-City has bought it twice — once as an implanted sensor, once as a virtual rehab episode. What it has never bought is the recurring, reimbursed service that sits between those two narrow slices and covers the whole cardiac panel.

✓ Verified

CardioMEMS in Your Own ASC

Tri-City Surgical Centers was among the first ambulatory surgery centers CMS approved to implant Abbott's CardioMEMS PA-pressure sensor, live since 2024. The practice already trusts remote hemodynamic data to drive heart-failure decisions.

✓ Verified

Five Electrophysiologists, One Device Clinic

Pacemakers, ICDs, and loop recorders implanted and managed in-house — with two additional EPs recruited in December 2025. Remote-transmission review is already a familiar weekly workflow, which makes RPM an extension of an existing habit rather than a new concept.

✓ Verified

A Live Virtual Cardiac-Rehab Program

The group already refers patients into an in-home virtual intensive cardiac rehab program by physician referral. Delivering cardiac care into the patient's home is already current practice at Tri-City, not a cultural leap.

★ Whitespace

Zero RPM or PCM Billed

Across 29 physicians, roughly 10 advanced practice providers, and 13 locations, no remote physiologic monitoring and no principal care management is billed anywhere in the group today. Every one of those dollars is currently unbilled.

The Pattern

Tri-City made the capital investment in heart failure — an ASC licensed for CardioMEMS, an expanding EP bench, a new Mesa campus — without the corresponding labor investment. No heart-failure clinic, no nurse navigator, no care-management team. The expensive, narrow, procedural half is built. The recurring, scalable, reimbursed half is not — and it is the half that protects the first one.

The Direction of Travel

In April 2026 the category the practice already buys from — virtual cardiac rehab — publicly extended into care management. That is market direction, not a criticism of any vendor: the longitudinal layer around the cardiac patient is going to get built by someone. The only question in front of Tri-City is whether the practice owns those economics or rents them.

Why It Matters to Owners

Tri-City recruits on physician group equity, ASC ownership, and real-estate ownership — an owner-operated practice, in a metro where several cardiology groups have already consolidated. Procedural revenue is exactly what a county running roughly 52% Medicare Advantage pressures hardest. A recurring, non-procedural service line is revenue diversification that supports independence, on the practice's own P&L.

The Operating Model

One Service Line, From Discharge to Steady State

A named, governed remote-care service line with its own owner, P&L, and scorecard, following the Medicare cardiac patient between visits — rather than a point solution bolted onto one diagnosis. CoachCare runs the engine; Tri-City's physicians govern every protocol and every clinical decision.

The Clinical Sequence — TCM → RPM → PCM
  • TCM Transitional Care Management catches the patient at discharge from Banner or Dignity: interactive contact inside two business days, medication reconciliation, and the post-discharge visit — the moment the 30-day readmission window is actually decided.
  • RPM Device-based physiologic monitoring — daily weights, blood pressure, pulse oximetry — as the continuous early-warning and titration layer across heart failure, coronary disease, hypertension, and post-procedure recovery.
  • PCM Principal Care Management for the high-risk cardiac condition the practice actually owns — cardiology-native longitudinal management between the acute event and stability, coded 99426 and 99427.
What CoachCare Delivers, So Tri-City Doesn't Staff It
  • Devices Cellular blood-pressure cuffs, scales, and pulse oximeters — sourced, shipped, configured, and supported by CoachCare, not by your front office.
  • Monitoring 24/7 alert triage and health-coach outreach staffed by CoachCare under Tri-City's protocols — no new clinical FTEs to hire across 13 locations.
  • Enrollment Physician-referral capture and telephonic outreach handled end to end, so panels fill without adding clinic load.
  • Documentation Every billed care-management minute is time-logged against a named protocol, with device-data provenance and a documented care plan written back to the chart — auditable by construction.
  • Billing Care-plan coding and monthly claims auto-generated by CoachCare's billing engine — capture holds as the panel scales.
Why PCM, and not Chronic Care Management. A specialist's care management is focused on one principal condition — resistant hypertension, coronary disease, heart failure — or on cardiovascular disease as a single domain, which is precisely what Principal Care Management is written for. Chronic Care Management assumes management of all of a patient's conditions, and it is increasingly billed by the patient's primary care practice, or absorbed into a prospective payment there. PCM is the code that fits the specialist's actual scope and does not collide with the PCP's.
The one coordination rule: RPM stacks with PCM for the same patient in the same month, and the two together are the whole longitudinal layer. The service line sets a single attribution policy per patient — RPM plus one principal-condition wrapper — with one shared care plan in NextGen, and PCM attribution is documented against the named cardiac condition so it never overlaps a primary-care care-management claim.
No mandatory model exposure today — pure-upside timing. The service line is margin-positive on clean fee-for-service economics before any value-based dollar, and the same infrastructure leaves the practice prepared if selection maps change.

The CY2026 Billing Stack

ServiceCodes~CY2026 MagnitudeCardiovascular Use at Tri-City
Transitional Care Management99495 · 99496~$200–$280 per dischargeThe catch at discharge from Banner or Dignity — and the on-ramp into RPM
RPM setup & device supply99453 · 99454 · 99445 (new)~$20 setup · ~$52/mo99445 makes 2–15-day post-discharge and post-procedure windows billable
RPM treatment management99457 · 99458 · 99470 (new)~$52 + ~$41 add'lMonthly review, GDMT titration, escalation before decompensation
Principal Care Management99426 · 99427~$60 + ~$50 add'lThe single high-risk cardiac condition (e.g., heart failure) for three months or more — the specialist's care-management code

The rates in this table are national non-facility amounts, rounded. The Value Analysis below uses MAC carrier/locality rates auto-resolved for Mesa, Arizona (zip 85205, carrier 03102 / locality 00).

Heart Failure
Coronary Artery Disease
Hypertension
Post-Discharge & Post-Procedure Recovery
Arrhythmia / Device Population
Direct · Bi-Directional · Native

Native NextGen Integration, In the Chart You Already Use

CoachCare integrates directly and bi-directionally with NextGen — Tri-City's team enrolls and monitors remote-care patients inside the NextGen Enterprise workflows they already use, with discrete vitals landing in the flowsheet and claims auto-generated every month. Nothing new for a clinician to learn, and nothing that lives outside the chart.

NextGen Enterprise EHR & PM · PxP portal One chart & work list Orders & flags Flowsheets / vitals Patient portal Billing workqueues CoachCare Remote care platform Cellular devices 24/7 monitoring Health coaches Enrollment team Billing engine FROM NEXTGEN Enrollment flags & trigger orders Patient health history BACK INTO NEXTGEN Discrete vitals — in the flowsheet, not PDFs Care summary & time-logged documentation Real-time enrollment status Claims — auto-generated, every patient, every month Clinicians never leave NextGen — the program lives in the chart they already use

One layer, not another vendor

Tri-City has publicly committed to consolidating onto fewer, deeper technology partners rather than stacking point solutions across the practice. A remote-care service line that writes back into NextGen is that same architectural decision applied to the clinical side.

The only one

CoachCare is the only care-management platform that provides automated claims creation via its own billing engine — the reason capture holds when the panel reaches four figures across 13 locations.

Auditable & secured by design

Every billed minute is time-stamped against a named protocol, with device-data provenance and a documented care plan in the chart. PHI moves under a signed Business Associate Agreement with HIPAA-compliant handling end to end.

"Key to achieving a program that is efficient, effective and sustainable is creating a seamless, intuitive user experience for the patient and provider — and that's what our EHR integration accomplishes."

The Operating Model Behind the Numbers

Clinical Governance & Escalation

The readmission exposure at the top of this page has a direct answer: a documented, escalation-governed clinical operating model, not a dashboard. Every RPM and PCM reading runs through one decision engine, with a hard emergency guarantee, defined routing, and a fixed post-discharge cadence. This is the protocol layer behind the modeled 433 avoided hospitalizations.

One Escalation Engine

Every reading, one decision logic

  1. Reading captured. Physiologic data from RPM devices and structured check-ins from PCM outreach all enter the same pipeline — one engine, both programs.
  2. Out of range → retake first. An out-of-range reading triggers a retake and a symptom check before anything reaches the practice, so noise is filtered at the source.
  3. Critical value → escalate regardless of symptoms. A critical reading routes immediately, symptomatic or not — the one case where filtering is bypassed.
  4. A trend is defined objectively. Three consecutive out-of-range readings at least one hour apart (blood pressure, glucose), or three within seven days (heart rate) — a trend is a number, not a judgment call.
  5. Unreachable → still governed. Voicemail plus a callback attempt; if a critical value or a qualifying trend exists, the escalation proceeds anyway.

Every escalation is time-logged against a named protocol on six fixed fields — an auditable record of each event, by construction:

VitalFindingsMethodContactOutcomeFollow-up
The Emergency Pathway — a hard safety guarantee

An active emergent symptom during any outreach call triggers 911 with the patient still on the line:

Chest painNew shortness of breathStroke signsSyncopeWorst-ever headacheSudden swelling

If the patient refuses, the clinic is looped in; if the clinic is unavailable, CoachCare activates 911 itself. CoachCare's urgent and emergent policy supersedes any local escalation preference — patient safety is never deferred to configuration.

Recent but not active — an emergent symptom within the prior 72 hours that is not present during the call — is handled per the practice's stated preference, not the emergency pathway.
Escalation Routing — Signal, Not Noise

Physicians are paged for what needs them, and nothing else

Emergency

Direct to 911

An active emergent presentation bypasses every queue and goes straight to emergency services, with the clinic notified.

Non-critical

Defined practice owner

An out-of-range value or qualifying trend that needs clinical eyes routes to a named practice team member — not a general inbox.

Stable / resolved

Documented FYI

A reading that self-resolves or returns to range is logged as a documented note — full visibility, without a page.

Post-Discharge Readmission-Prevention Cadence

The three touches that intercept a readmission before it happens

An emergency-department visit or hospitalization in the prior 60 days automatically triggers a fixed three-touch cadence across the first two weeks after discharge — the exact window in which a low-rated admitting hospital's readmission risk is decided.

Day 1–2Stabilize & reconcile
  • Identify precipitating factors for the admission
  • Full medication reconciliation
  • Confirm PCP / specialist follow-up booked within 7–14 days
  • Structured symptom assessment
Day 5–8Verify & adjust
  • Verify medication adherence
  • Re-evaluate the admission triggers
  • Confirm the follow-up appointment was attended
  • Verify ordered labs were completed
Day 12–14Review & re-assess
  • Medication and risk-factor review
  • Review the outcomes of the follow-up visit
  • Symptom re-assessment against baseline
  • Document and escalate any residual risk
This cadence is the engine behind the numbers. Roughly 73% of Tri-City's admissions land at three 2-star Banner hospitals, and there is no post-discharge program watching that window today. The three-touch protocol above — each touch documented and escalated through the same engine — is precisely what converts that exposure into the 433 modeled avoided hospitalizations, roughly $6.49M of avoided acute cost, shown in the Value Analysis below.
Continuity — no patient falls through. When a patient can't be reached, the event escalates to the clinic and re-escalates on a fixed cadence until it is closed, and the practice is notified at every decision point. Nothing in the model depends on a single successful phone call.
CoachCare Value Analysis · Modeled for Tri-City Cardiology

The Value Analysis

A 24-month forecast for the cardiology remote-care service line, built on a discovery-stage panel estimate of ~30,400 Medicare patients — roughly 14,700 in traditional fee-for-service plus a comparable Medicare Advantage population at Maricopa County's ~52% MA penetration; 41 referring providers; one CoachCare-funded on-site enrollment specialist; MAC-locality rates for Mesa (zip 85205); NextGen integration. RPM and PCM bill cleanly on the fee-for-service half of that panel; the Medicare Advantage half requires plan-by-plan confirmation in discovery. Avoided-hospitalization savings are shown as clinical value, not revenue.

Active Program Enrollments Under Remote Care

Monthly active census by program — active program enrollments (services), not unique patients. Reaches 7,017 active enrollments at Month 24, equal to 5,779 unique patients after deduplication for cross-program dual enrollment. Enrollment begins in month 1 and ramps via physician referral across 41 providers, one CoachCare-funded on-site enrollment specialist, and telephonic outreach, net of discharges.

Monthly Economics — Reimbursement, Fees, Net to Practice

Monthly net reimbursement (after denials and coinsurance bad debt) against all CoachCare fees, and the net that stays with the practice. The series is inclusive of one-time implementation and integration items, which land in month 1 — and the service line is still net-positive to the practice in that first month (+$1,438), and in every month thereafter. The on-site enrollment specialist is CoachCare's expense and is never subtracted from practice margin.

24-Month Net Reimbursement Mix

$8,159,108 total across the two-program cardiology stack — RPM plus PCM.

The Financial Summary

ProgramNet ReimbursementCoachCare FeesPractice Margin
RPM — remote physiologic monitoring$6,209,226$3,465,190$2,744,037
PCM — principal care management$1,949,882$1,017,686$932,196
Implementation, integration & ancillary$196,490−$196,490
24-month total$8,159,108$4,679,365$3,479,743
By YearYear 1Year 224-Month
Net reimbursement$2,005,076$6,154,032$8,159,108
CoachCare fees$1,156,575$3,522,790$4,679,365
Net to practice (after fees)$848,501$2,631,242$3,479,743
Enrollment, device logistics, 24/7 monitoring, and billing capture are delivered by CoachCare — no new practice headcount required. The on-site enrollment specialist is CoachCare's expense and is never subtracted from practice margin.

24-month practice margin: 42.6% of net reimbursement (Year 1 42.3%, Year 2 42.8%).

Full model available as a companion workbook.

Scenario Explorer — Build Your Own Forecast

Adjust the assumptions and watch the 24-month forecast recompute live. Census is reported as active program enrollments.
24-mo net reimbursement
$8,159,108
24-mo net to practice
$3,479,743
Active enrollments · M24
7,017
Unique patients · M24
5,779
Hospitalizations avoided
433

At the modeled scenario the explorer reproduces the workbook run: Month-24 active census of 5,249 RPM · 1,768 PCM = 7,017 enrollments (5,779 unique patients), and 24-month net reimbursement of $8,159,108.

Clinical & Operational Value

What the Service Line Produces Besides Revenue

Reimbursement is the reason the service line is self-funding. It is not the reason to build it. Over 24 months the modeled program generates a continuous clinical record of the cardiac panel between visits — and absorbs the care-management labor a 29-physician group would otherwise have to hire.

155,859

Billed Claims / Units

Recurring, subscription-like professional-fee volume across the RPM and PCM stack over 24 months.

681,884

Physiologic Readings

A continuous picture of the heart-failure, coronary, hypertension, and post-discharge panels between office visits.

433

Hospitalizations Avoided

≈ $6.49M in avoided acute cost at $15K per admission — clinical value, excluded from every revenue figure here.

69,234

Care-Team Hours Absorbed

Monitoring, outreach, and documentation performed by CoachCare — roughly 33.3 FTE-equivalents of work Tri-City does not have to hire.

The device population is the natural first cohort. A five-electrophysiologist arrhythmia center already reviews remote transmissions on a weekly cadence, and the CardioMEMS population already generates remote hemodynamic data. Layering reimbursed RPM and a longitudinal PCM wrapper onto patients whose remote data you are already reading is the lowest-friction place to start — and it makes the existing device investment produce recurring revenue rather than only clinical signal.
Implementation

Chartered in 30 Days.
Enrolling by Day 45.

CoachCare runs the service line's engine: enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation. Tri-City's physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new headcount; practice staffing formalizes only as census grows.

0–30 Days

Charter & Configure

Named service-line owner, P&L, and scorecard; NextGen integration and billing configuration; protocol sign-off for heart failure, coronary disease, hypertension, post-discharge, and device-population pathways.

31–90 Days

First Cohorts at the Discharge Edge

Start where the exposure is: patients discharging from Banner and Dignity, plus the arrhythmia-center and CardioMEMS populations already generating remote data. TCM-to-RPM handoff live; first billable claims by day 45.

91–180 Days

Scale Across the Footprint

Referral engine extended across all 41 referring providers and the East Valley clinic network; PCM layered onto the principal-condition panel alongside RPM; monthly scorecard to practice leadership.

181–365 Days

Steady-State Service Line

Roughly 3,550 active program enrollments — about 2,924 unique patients — by month 12, scaling toward 7,017 enrollments and 5,779 unique patients by month 24, with recurring professional-fee revenue and a continuous clinical picture of the cardiac panel between visits.

About CoachCare

The Experience to Get It Right

The service line described on this page runs on infrastructure already proven at national scale.

500,000+

Patients Managed

Over 400 conditions managed for 500,000+ patients.

10,000+

Clinicians on the Platform

Providers running remote care programs day to day.

1,000+

Programs Implemented

Remote care programs launched on this infrastructure.

5M+

Claims Generated

Care-plan coding and billing behind more than 5 million claims.

100M+

Vitals Recorded

Over 100 million vitals recorded and 4 million+ care actions delivered.

Policy Watch · CMS-1848-P

2027 Proposed Rule Insights

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.

1

The Proposal Is Confined to RPM

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 $1,949,882 of the modeled $8,159,108 in 24-month net reimbursement, and the TCM touch at discharge is outside the proposal entirely. Neither is in scope.

2

CoachCare Is Building the Contingencies Now

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.

3

ACCESS Moves Remote Care to Risk-Based PMPM

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.

What the Proposal Actually Takes Off This Forecast

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.

−20.6%
The headline per-code cut — device supply (99454 / 99445), the code the proposal reprices hardest.
−8.8%
The RPM patient-year, because device supply is only 31% of it — the management codes barely move.
−6.8%
The whole service line, because PCM carries 23.9% of the forecast and is not in scope.
RPM alone — the only code family in scope$6,209,226 over 24 months
−$546,936
−8.8% of RPM
The whole service line — RPM + PCM$8,159,108 over 24 months
−$553,025
−6.8% of the whole

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.

RPM, retained at CY2027 proposed rates The proposed reduction PCM — not in scope

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 $553,025, RPM accounts for $546,936 and the care-management arm for $6,089.

Where the Proposal Lands, Code Family by Code Family

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 familyWhat CMS proposedCY2026CY2027 proposedChange
In scope — remote physiologic monitoring
99454 / 99445 · device supplyPractice expense recrosswalked$52.11$41.38−21%
99457 · management, first 20 minDirect practice expense removed$51.77$49.59−4%
99458 · management, each addl 20 minDirect practice expense removed$41.42$40.39−2%
99453 · setup and patient educationCrosswalked; one-time per patient$21.71$20.03−8%
Not in scope — the codes the proposal does not reach
99424–99427 · PCMNo structural change proposed$67.80$67.00−1%
99495 / 99496 · TCMNot addressed by the proposalOutside 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.

None of this is final. CMS-1848-P is a proposed rule. Comments are due September 14, 2026, the final rule is expected in early November, and it takes effect January 1, 2027. CoachCare is leading the advocacy — filing comments, putting the device cost and pricing evidence in front of CMS that the rule itself states the agency does not have, and helping practices file their own. This practice gets the final rates, and the model rerun against them, the week they publish.