The hospital already owns every hand-off that decides whether a rural patient with heart failure, diabetes, COPD or kidney disease stays home: the clinic visit, the emergency department, the swing bed, the discharge. What it does not own yet is the month in between. Since January, Medicare pays a Rural Health Clinic for that month, on top of the visit. This is the 24-month plan to bill for it, with CoachCare staffing the program inside TruBridge.
Two counts, two jobs. The headline is 472 unique patients at month 24; the enrollment chart and the Scenario Explorer show 724 active program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments.
A 25-bed Critical Access Hospital that kept a 24/7 emergency department, an ICU, same-day surgery, a swing-bed program running at more than 400 admissions a year and two certified Rural Health Clinics in an 11,000-person county, and added the second clinic in December 2024. An organization that already runs the discharge is the right organization to run the month after it.
Candler Medical Group, certified in 2011 and running 22,484 visits in CY2024 across seven practitioner FTE, and Candler Family Health Center, certified in December 2024. Both bill on the hospital's own cost report, which is the rail the CY2026 care-management codes ride on.
431 swing-bed admissions in 2025 out of 635 total, with an inpatient payer mix that is 84% Medicare. Every one of those discharges is a transitional-care episode the hospital already controls end to end.
The emergency department saw 7,045 patients in 2025, held 658 in observation and transferred 536 out. Each of those events is a signal the care team can act on the same week rather than a chart note found at the next visit.
The hospital and both clinics run on TruBridge (CPSI), with the hospital's own billing office filing the RHC claims. CoachCare integrates into that chart, so referral orders, vitals, documentation and billing-ready claims stay in one place.
One structural fact completes the picture: no remote patient monitoring, chronic care management or advanced primary care management program is visible at meaningful scale in CY2024 Medicare claims or in the hospital's public materials. Case management works the inpatient stay. Nobody is paid to work the thirty days after it.
The clinics serve a county where nearly one resident in five is 65 or older, one in six lives below the poverty line, and most of the Medicare population is enrolled in Medicare Advantage. Distance is the adherence problem. Daily readings and a monthly call are how a rural clinic reaches a patient it sees in person twice a year.
Three things changed at once for a Rural Health Clinic in 2026: how care management is billed, what remote monitoring can bill for, and where the state's rural health money is going.
Through September 2025, an RHC billed care management as one bundled code. From January 2026, RHCs bill chronic care management, remote monitoring and advanced primary care management as individual codes at national non-facility amounts, in addition to the all-inclusive rate for the visit. Each service is paid on its own.
New CPT codes for 2 to 15 days of device data and for the first 10 minutes of management remove the 16-day floor that used to block episodic monitoring. A swing-bed discharge or an observation stay can now be followed by a billable two-week monitoring window, next to the standard monthly stack.
CMS awarded Georgia $218.8 million for Year 1 of the Rural Health Transformation Program in December 2025 and a further $93.3 million in August 2026. The state's plan names telehealth access points, care-network continua and pre-implementation support for rural hospitals preparing for a value-based track. This hospital is on the state's eligible-hospital list by its Critical Access designation. No award or participation is asserted here.
A named service line with its own P&L and scorecard, following the Medicare patients the clinics already know, inside the TruBridge chart the hospital already runs. Remote monitoring for the conditions that produce readings, chronic care management for patients with two or more conditions, and advanced primary care management where the dual-eligible mix makes it the better monthly code.
| Service | Codes | CY2026, Georgia locality 99 | Use across the panel |
|---|---|---|---|
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $19.57 setup · $46.58/mo | Hypertension, heart-failure and diabetes cohorts; 99445 opens 2–15-day windows after a discharge |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $48.78 + $39.55 add'l · $24.56 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $63.30 + $48.01 add'l | Two or more chronic conditions; the longitudinal wrapper |
| Advanced primary care management | G0556 · G0557 · G0558 | $15.70 · $51.25 · $111.80/mo | The primary-care panel by complexity tier; the top tier is the dual-eligible tier |
| Transitional care management | 99495 · 99496 | $208.27 / $282.43 per discharge | Every swing-bed, inpatient or observation discharge; not in the forecast below |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 30439 (Palmetto GBA, Georgia locality 99), the basis the Value Analysis below is priced on. Rural Health Clinics bill the care-management codes at national non-facility amounts, which run above the Georgia locality on every code in this table.
A Critical Access Hospital is outside the federal readmission penalty programs, so this is not a penalty argument. It is a transfer argument. A patient who decompensates at home in Candler County goes to the emergency department, and from there is often transferred out of the county. The program's job is to catch the decompensation a week earlier, by phone and by reading, and route it to the clinic.
Any emergency visit, observation stay or hospitalization in the last 60 days triggers three touches inside two weeks. For a hospital that owns the swing bed and the emergency department, the trigger fires the day the patient leaves, and when the patient was admitted it is also the TCM episode: contact within two business days, the visit within 7 or 14 days.
Reach the patient, reconcile medications against the discharge instructions, confirm the device is transmitting.
Symptom and reading review, barriers to the plan, follow-up appointment confirmed with the clinic.
Close the episode or extend it; anything trending is escalated through the engine below.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling. CoachCare's urgent and emergent policy supersedes any client-specific preference. If the patient refuses, the clinic is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or nurse the clinic designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a symptom check that is clean closes the loop with a chart note and nothing else. The clinic's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule, the clinic is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
A 24-month forecast for the RPM + CCM + APCM stack: a 1,600-patient Medicare panel across the two Rural Health Clinics and the Pulaski site, all of it in scope for Year 1, 9 referring clinicians plus CoachCare's enrollment outreach, Georgia locality rates for ZIP 30439, and the TruBridge integration. Transitional care and the national RHC rate rail are not in these numbers.
| Program | Net reimb. | CoachCare fees | Net to hospital |
|---|---|---|---|
| RPM | $590,123 | $338,856 | $251,267 |
| CCM | $409,680 | $203,259 | $206,421 |
| APCM | $218,827 | $121,596 | $97,232 |
| Implementation, TruBridge integration, outreach | — | $36,383 | −$36,383 |
| 24-month total | $1,218,631 | $700,093 | $518,537 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the hospital and never deducted from its margin. | |||
24-month margin: 42.55% of net reimbursement (Year 1 41.42%, Year 2 43.24%).
Year 1 is $192,135 net to the hospital on $463,832 of net reimbursement; Year 2 is $326,402 on $754,798. Month 1 is −$5,404 as the one-time setup lands ahead of the ramp; monthly net is positive from month 2 onward.
Recurring care-management and monitoring volume over 24 months, filed on the RHC claim by the hospital's own billing office.
Blood pressure, weight and glucose, a continuous picture of the hypertension, heart-failure and diabetes cohorts between visits.
About $651K in acute-care cost that never gets spent, at $15,000 per admission, and that many transfers that stay in the county.
About 8,659 care-team hours of monitoring, outreach and documentation carried by the service line, not by hospital staff.
APCM reaches its ceiling of 168 enrollments in month 5, CCM its ceiling of 192 in month 8, and RPM its ceiling of 364 in month 12. From there the census holds at 724 active enrollments, 472 unique patients. The binding constraint on this forecast is the size of the Medicare panel, not outreach capacity. That is what the clinics' own chart counts, the second clinic's first full year and a confirmed clinician roster all move.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 364 | 1,600 in scope × 65% eligible × 35% acceptance | Month 12 |
| CCM | 192 | 1,600 × 40% × 30% | Month 8 |
| APCM | 168 | 1,600 × 35% × 30% | Month 5 |
| At month 24 | 724 | Active program enrollments = 472 unique patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working the two clinics. Without that specialist the same ceilings are reached months later and remote monitoring never fills inside the forecast; the 24-month net reimbursement falls to $899,855. The specialist cannot raise a ceiling, but reaching it in month 12 instead of never is worth $318,776 over 24 months, and it is CoachCare's payroll.
A Rural Health Clinic bills the care-management codes at national non-facility amounts on the RHC claim. The forecast on this page uses the Georgia locality amounts, which sit below national on every code in the basket. Priced at the national amounts with the same census, 24-month net reimbursement is $1,293,677, and because CoachCare's fees are per active patient per month, the whole difference, $75,046, is the hospital's.
The hospital and both clinics run on TruBridge (CPSI). CoachCare connects to it through an HL7 and FHIR integration: eligibility flags and referral orders leave the chart; monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The hospital's own billing office files the RHC claims it already files. The integration runs in parallel with onboarding, so it does not gate the first enrollments.
the integration is built alongside onboarding, training and care-team assignment; the first enrollments do not wait for it.
a physician, NP or PA flags an eligible patient and submits the referral from inside TruBridge; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the hospital's own billing office already runs for the RHC claim. No PDFs, no re-keying.
Georgia's Rural Health Transformation Program received $218.8 million for its first year in December 2025 and a further $93.3 million in August 2026. The state's plan funds telehealth access points, care-network continua, workforce, and pre-implementation support for rural hospitals preparing for a value-based track, and it names Critical Access Hospitals among the eligible recipients. This hospital is on the state's eligible-hospital list by designation. No award or participation is asserted on this page.
A consented longitudinal panel. Documented monthly care management. Continuous physiologic data. A working readmission-prevention loop. Whichever value-based track a rural hospital in Georgia is offered next, that is the readiness it will be measured on, and it is what this service line builds under fee-for-service first, while every month of it is paid.
Georgia Medicaid fee-for-service does not reimburse remote patient monitoring, so the forecast on this page is Medicare only, traditional and Medicare Advantage. Medicaid patients still benefit from the same care team where the clinic chooses to enroll them; they are not in any figure above.
CoachCare operates as the service line's engine while the clinics' physicians and advanced practitioners govern protocols and every clinical decision. Full-service delivery means launch needs no new hospital headcount; the TruBridge integration runs in parallel with onboarding, and the first enrollments follow the first referral orders.
TruBridge integration scoped and started; named program lead at the hospital; P&L and scorecard; RHC claim configuration with the billing office; protocol sign-off for the hypertension, diabetes, heart-failure and COPD pathways; the swing-bed and observation discharge trigger wired to the three-touch cadence.
APCM and CCM across the two-plus-condition panel and RPM for the hypertension and heart-failure cohorts; CoachCare's on-site enrollment specialist working both clinics; the post-discharge cadence live from day one.
APCM fills in month 5, CCM in month 8, RPM in month 12; monthly scorecard to the executive team and the Hospital Authority.
Re-validate eligibility against chart data, bring the second clinic's full first year into the panel, add transitional care at every swing-bed discharge, and align the program's reporting with whatever value-based track the state offers next.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline. Here is what they do to the forecast on this page, priced at the hospital's own Georgia locality amounts rather than national averages.
The proposals reach the remote-monitoring family only. Chronic care management and advanced primary care management are not in them, and on this forecast those two carry $628,508 of the $1,218,631 in 24-month net reimbursement. Their own amounts move by a point or two, so $10,639 of the $64,107 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement, with the software platform, device logistics and program enablement priced separately, and an MSO-style arrangement in which CoachCare manages the staffing while the hospital owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. Fee-for-service code cuts and that shift are the same policy argument. Pay for results rather than for device-months. A rural hospital preparing for a value-based track is already on that road.
Three numbers, each smaller than the last, because each one sits on a larger base. Both bars are drawn on one shared dollar scale, so the red can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Palmetto GBA Georgia locality 99 amounts, non-facility, on this forecast's own billing mix. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B, so the movement can be read without a locality in the way. The repricing above uses Georgia amounts; the two bases do not reconcile to the dollar, by design.
| In scope: remote monitoring | ||||
|---|---|---|---|---|
| Code | What it pays for | CY2026 | CY2027 | Change |
| 99453 | Setup and patient education | $21.71 | $20.03 | −7.7% |
| 99445 | Device supply, 2–15 days | $52.11 | $41.38 | −20.6% |
| 99454 | Device supply, 16–30 days | $52.11 | $41.38 | −20.6% |
| 99457 | Treatment management, first 20 minutes | $51.77 | $49.59 | −4.2% |
| 99458 | Treatment management, each additional 20 minutes | $41.42 | $40.39 | −2.5% |
| 99470 | Treatment management, first 10 minutes | $26.05 | $20.69 | −20.6% |
| Not in scope: care management | ||||
| 99490 | Chronic care management, first 20 minutes | $66.13 | $64.04 | −3.2% |
| 99439 | Chronic care management, each additional 20 minutes | $50.44 | $49.92 | −1.0% |
| G0556 | Advanced primary care management, level 1 | $16.37 | $16.09 | −1.7% |
| G0557 | Advanced primary care management, level 2 | $53.78 | $53.20 | −1.1% |
| G0558 | Advanced primary care management, level 3 | $117.24 | $116.91 | −0.3% |
The device-supply and short-treatment codes are held to a one-year maximum reduction by section 1848(c)(7) of the Act, which phases any decrease of 20 percent or more over two years. CY2027 is the capped year; the remainder of the crosswalk lands no earlier than CY2028.
The comment period on CMS-1848-P closed September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare is leading advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
The service line 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 CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Six reasons this fits Candler County Hospital specifically, not remote care in general.
Individual care-management codes on the RHC claim, in addition to the all-inclusive rate, filed by the hospital's own billing office. The 2026 change from the bundled code is the reason the forecast on this page exists, and the program is built around it.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The 4.2 FTE-years of work in the forecast never touch the hospital's staffing plan.
Every swing-bed, inpatient or observation discharge of an enrolled patient fires the three-touch cadence the same day, every ED visit is a trigger, and critical readings escalate through one engine whose urgent policy supersedes any preference. A hospital that owns the swing bed and the clinic is the ideal shape for this program.
An HL7 and FHIR integration carries referral orders out and vitals, documentation, enrollment status and billing-ready claims back in. One chart for clinicians, one workflow for the billing office, no second system.
Every device ships with its own cellular connection, so the program does not depend on home broadband or a smartphone app. Patient materials are written for a rural Medicare population, and every patient has a named care manager who calls.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid, which is why the plan is measured twice before it goes to paper. The forecast, the Disclosures and the workbook behind this page are yours to keep either way.