Medicare now pays — every month — for continuous remote care of heart failure, coronary artery disease, atrial fibrillation, and hypertension. This practice, whose founder helped adapt NASA telemetry so a moving ambulance could transmit an EKG to the emergency room, bills none of those codes today. This is the plan to claim them.
Baker-Gilmour is not being asked to adopt someone else's idea. The founder's signature achievements — EKGs transmitted from moving ambulances, cardiac patients in small rural hospitals monitored from metropolitan coronary care units — are the direct ancestors of today's remote physiologic monitoring and chronic care management. The only thing missing is the modern program.
The founder opened his Jacksonville practice in 1953 — the founding of a cardiovascular institution now in its eighth decade of independent practice.
Dr. Baker helped adapt the NASA technology that monitored astronauts' EKGs into systems transmitting EKGs from moving ambulances to emergency rooms.
He developed remote cardiac patient monitoring — connecting patients in small rural hospitals to coronary care units in larger metropolitan hospitals.
No remote physiologic monitoring or chronic care management program is marketed anywhere on the practice's site today. The founder's category sits unclaimed, in his own practice.
Dr. Kay E. Gilmour — Jacksonville's first female critical care practitioner and the first female Chief of Cardiology at Memorial Hospital — extended that legacy of firsts. The 2026 opportunity is to be first again: the independent cardiology group in Northeast Florida that runs remote care as a governed, margin-positive service line.
Since January 1, 2026, CMS's Transforming Episode Accountability Model (TEAM) holds hospitals financially accountable for 30-day surgical episode cost and quality. Both hospitals where Baker-Gilmour's cardiologists practice are mandatory participants — and a 2026 billing change makes the operational answer newly reimbursable.
HCA Florida Memorial Hospital (CCN 100179) — where a Baker-Gilmour physician directs the electrophysiology laboratory — and Flagler Hospital (CCN 100090) in St. Augustine are both mandatory TEAM participants in the Jacksonville CBSA (27260), model window 2026–2030. Their surgical episodes, including CABG, now reconcile against CMS target prices with 30-day spend and readmissions on the line.
New CPT codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) remove the 16-day floor that used to block episodic monitoring — making post-discharge and post-procedure windows cleanly billable for the first time.
The Jacksonville office is directly across the street from HCA Florida Memorial; the St. Augustine office sits on the Flagler Hospital campus. The discharges those episodes are judged on walk past your front door — a structural position no other independent group can copy.
A named service line with its own P&L and scorecard, rather than a device pilot bolted onto one condition. CoachCare runs the engine, Baker-Gilmour's physicians govern it, and the program follows the Medicare patient between every office visit.
| Service | Codes | CY2026 Magnitude | Cardiovascular Use |
|---|---|---|---|
| Transitional care management | 99495 · 99496 | ~$200 / ~$280* | Every HF and post-procedure discharge from Memorial and Flagler |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · $50.00/mo | 99445 unlocks the 2–15-day post-discharge window |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.12 + $41.22 add'l | Monthly review, titration, escalation |
| Principal care management | 99426 · 99427 | $67.57 + $53.69 add'l | The principal cardiac condition — HF, CAD, resistant HTN — ≥3 months |
Dollar figures are CY2026 Physician Fee Schedule amounts auto-resolved for zip 32216 (Florida carrier 09102, locality 99), as used in the Value Analysis below. *TCM shown at national non-facility magnitude — not included in the modeled forecast.
The same infrastructure — enrollment, devices, alerts, outreach, documentation, billing — is the connective tissue for the TEAM episodes your hospitals now own, and for every other lever the practice cares about.
Baker-Gilmour runs a Veradigm ambulatory environment, with patients already using the FollowMyHealth portal. CoachCare's integration catalog includes Veradigm: the program is designed to work from the chart your team already lives in, not beside it.
Eligible patients are identified and enrolled from practice data, so your staff never maintains a separate registry or learns a new system.
Cellular device readings and care-team documentation return to the practice as structured data — a continuous record between visits, not a stack of faxed PDFs.
Time logs, care plans, and consent capture are generated automatically to the standard each code family requires.
CoachCare's billing engine assembles claim-ready detail for every enrolled patient, every month — the capture-rate discipline that decides program economics.
Patients keep the FollowMyHealth experience they already know.
A 24-month forecast for the practice: an estimated 2,200-patient Medicare panel across both offices, six referring providers plus a dedicated on-site enrollment specialist funded by CoachCare, CY2026 rates auto-resolved for zip 32216 (Florida carrier 09102, locality 99). The service line is RPM + PCM — physiologic monitoring plus Principal Care Management on the principal cardiac condition. TEAM episode upside and avoided-readmission savings are not in these numbers — they are upside on top.
| 24-month, by program | Net reimb. | CoachCare fees | Practice margin |
|---|---|---|---|
| RPM | $1,034,204 | $584,667 | $449,537 |
| PCM | $674,486 | $350,947 | $323,539 |
| Implementation & ancillary | — | $42,043 | −$42,043 |
| Total, 24 months | $1,708,690 | $977,657 | $731,033 |
| By period | Net reimb. | CoachCare fees | Practice margin |
|---|---|---|---|
| Year 1 | $543,803 | $318,924 | $224,879 |
| Year 2 | $1,164,887 | $658,733 | $506,154 |
| 24 months | $1,708,690 | $977,657 | $731,033 |
| Includes an on-site enrollment specialist staffed at CoachCare's expense — embedded value, never subtracted from practice margin. | |||
24-month practice margin: 42.8% of net reimbursement (Year 1 41.4%, Year 2 43.5%). Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous clinical picture of the HF, CAD, AFib, and HTN panels between visits.
≈ $1.08M in avoided acute cost at $15K per admission — and direct relief on your hospitals' 30-day episodes.
~15,534 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 Baker-Gilmour's 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 your medical assistants and front desk keep their current workflow.
Named physician owner, P&L, scorecard; Veradigm integration and billing configuration; protocol sign-off for the HF, CAD, AFib, and HTN pathways; panel validation against practice chart counts.
Heart failure and post-procedure discharges from Memorial and Flagler, plus the device-clinic population — first billable enrollments by day 45, outreach within two business days of discharge.
Jacksonville and St. Augustine panels enrolling to ceiling pace; hypertension cohort deepens; monthly scorecard — census, capture rate, revenue per patient-month, readmission signal — to practice leadership.
Program results packaged for Memorial and Flagler: documented 30-day support on the episodes CMS reconciles against them, and the case for a formal cardiology partnership on that work.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 conditions managed for 500,000+ patients.
Providers running remote care programs on CoachCare today.
Remote care programs implemented for provider organizations.
Care-plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions.
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 $674,486 of the modeled $1,708,690 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 $90,084, RPM accounts for $86,509 and the care-management arm for $3,575.
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 Baker-Gilmour specifically, not remote care in general.
CoachCare's integration catalog includes Veradigm: eligibility flags and orders leave the EHR, and discrete vitals, care documentation and claim-ready charges come back in as structured data. Patients already use the FollowMyHealth portal, so the program runs from the chart your team lives in, not beside it.
Enrollment outreach, the care team, cellular devices, 24/7 alert triage and billing preparation are CoachCare's payroll. The practice inherits a running program at a 42.8% margin, margin-positive from month two, with no hiring cycle. On-site enrollment is our expense — telephonic outreach converts about 8%, so we staff the clinic instead.
Your cardiologists set the protocols, sign the care plans and make every clinical decision, and claims go out under the group's own entity and NPIs. CoachCare supplies the staff, devices, platform and billing preparation under that governance. It is the operating model an independent institute keeps control of.
Every high-risk discharge from HCA Florida Memorial and Flagler Hospital opens a transitional-care window and a first-14-day monitoring window. The same infrastructure that bills those touches also moves the 30-day spend and readmissions on which those hospitals' TEAM episodes are now reconciled. One remote care service line covers the standalone panel and the episode performance.
The practice bills none of these codes today, so there is no existing vendor to rip out and no parallel workflow to retire. The program is built once, inside Veradigm, for the heart-failure, coronary-artery-disease, atrial-fibrillation and hypertension panels the group already manages.
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.