How Ocala Kidney Group turns continuous remote care for chronic kidney disease, resistant hypertension, and the dialysis-transition panel into new fee-for-service revenue — and a shared-savings engine for its Integrated Kidney Care of Florida risk contract.
This is not a turnaround story. Ocala Kidney Group is one of Marion County's oldest independent nephrology practices, physician-owned, procedurally sophisticated, and already inside a Medicare kidney-care risk contract. The strategic question is not whether to add remote care — it is how to make one build pay twice: as new fee-for-service revenue and as the clinical engine behind shared savings.
Serving Marion County since 1984 — independent, no private-equity backing. ~10–11 board-certified nephrologists plus 8 APRNs across three offices (Ocala main, Route 200 West, and Leesburg).
A dedicated Dialysis Vascular Access Center staffed by two FASDIN interventional nephrologists — clinical depth and a procedural platform most community groups can't match.
A confirmed CKCC participant in Integrated Kidney Care of Florida (DaVita IKC), with Dr. Rebecca Ong on the KCE governing body. The accountable-care infrastructure is already yours.
Marion County is 28.5% age 65+ — roughly twice the national share — with CKD + hypertension the near-universal chronic pair in older Floridians. The panel is right there.
The one thing missing is the service line itself. No RPM, PCM, telehealth, or patient-monitoring program is marketed anywhere in the practice today — a clean greenfield, with no incumbent vendor to rip out and no workflow to unlearn.
Most practices weigh remote care on fee capture alone. Ocala Kidney Group is different: it already carries shared-savings exposure on the total cost of care for its FFS-aligned CKD and ESRD patients. Every RPM reading and PCM touch that slows progression, controls blood pressure, or prevents a crash-start bills today and moves the number the KCE is measured on.
A confirmed participant in the DaVita-managed Kidney Contracting Entity, with Dr. Rebecca Ong on its governing body. KCE quality climbed from 87.5% (PY2022) to 90% (PY2024), and PY2022 generated $833,116 in shared savings reinvested into the program. RPM and PCM feed that machinery directly.
New codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) remove the old 16-day floor, making post-hospitalization and dialysis-transition monitoring windows cleanly billable — on top of the established 99453 / 99454 / 99457 / 99458 stack.
Slower CKD progression delays dialysis — the KCE's single largest cost driver. Home BP monitoring controls resistant hypertension. Early decompensation alerts convert emergent crash-starts into planned, optimal starts. Each is a shared-savings lever, not just a CPT line.
Not a point solution bolted onto one diagnosis — a named, governed service line with its own owner and scorecard, following the CKD patient between visits on the chart you already use. Two reimbursable programs, one shared infrastructure.
| Service | Codes | ~CY2026 Magnitude | Nephrology Use |
|---|---|---|---|
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$50/mo | BP & weight monitoring; 99445 unlocks 2–15-day windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$50 + ~$40 add'l | Monthly review, titration, escalation |
| Principal Care Management | 99426 · 99427 | ~$80 + ~$60 add'l | Single high-risk condition (CKD) ≥ 3 months |
Illustrative national non-facility magnitudes. The value analysis below uses MAC-locality rates auto-resolved for zip 34471 (First Coast Service Options, Florida). Verify against the current CY Physician Fee Schedule.
The same infrastructure — enrollment, cellular devices, 24/7 alert triage, nurse outreach, billing capture, analytics — powers each lever that moves both the practice's revenue and the KCE's shared-savings math. Build once, reuse everywhere.
Ocala Kidney Group runs on Greenway — confirmed via the myhealthrecord.com patient portal. CoachCare integrates natively so that enrollment, discrete vitals, care documentation, and auto-generated claims live inside the Greenway workflow. Your team never learns a new platform; the program lives in the record they already touch every day.
Catalog integration pricing shown for reference. Ocala Kidney Group's exact Greenway product — Intergy versus Prime Suite — and version should be confirmed in contracting, as it determines the precise interface path (Intergy carries modern FHIR/USCDI APIs; Prime Suite is more constrained).
"Key to achieving a program that is efficient, effective and sustainable is creating a seamless, intuitive experience for the patient and provider — and that is what native EHR integration accomplishes."
A 24-month forecast for the RPM + PCM nephrology service line — a ~10,780-life total-Medicare panel, roughly 19 referring providers, MAC-locality rates for zip 34471, Greenway integration. CKCC shared-savings upside and avoided-hospitalization dollars are not in these revenue numbers; they are upside on top of the reimbursement run below.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $546,300 | $1,669,910 | $2,216,210 |
| PCM net reimbursement | $184,008 | $576,229 | $760,237 |
| Total net reimbursement | $730,308 | $2,246,139 | $2,976,447 |
| Practice margin (after fees) | $304,241 | $955,842 | $1,260,083 |
| Fees include implementation, Greenway integration, devices, 24/7 monitoring, and enrollment — embedded value already reflected in the margin above. | |||
Figures are illustrative and modeled — verify against practice data. Full model available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months.
A continuous clinical picture of the CKD and hypertension panels between visits.
≈ $2.31M in avoided acute cost at $15K per admission — and direct CKCC shared-savings relief.
≈ 12.1 FTE-years of monitoring, outreach, and documentation absorbed by the service line.
CoachCare operates as the service line's engine — enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation — while Ocala Kidney Group's nephrologists govern protocols and every clinical decision. Full-service delivery means launch requires no new headcount; the pilot cohort proves the unit economics before any scale commitment.
A natural proving ground: the CKD stage 4–5 and resistant-hypertension panel at the main Ocala campus, co-located with the Dialysis Vascular Access Center, where the highest-acuity patients already concentrate. Modeled census reaches roughly 200 active enrollments by Day 90 (months 1–3: 41 → 108 → 201), footnoted honestly — the real funnel is set in protocol design.
Named owner and scorecard; Greenway integration and billing configuration; confirm the exact EHR product and version; segment the FFS/CKCC vs Medicare Advantage panel; protocol sign-off for CKD and hypertension pathways.
Stage 4–5 CKD and resistant-hypertension patients at the Ocala main campus — referral plus telephonic enrollment, cellular BP and weight devices, protocolized titration under nephrology direction.
Ocala main, Route 200 West, and Leesburg all enrolling; the Leesburg clinic extends into the retiree corridor; balanced scorecard reporting monthly to service-line governance.
Full-panel enrollment; a formal reporting loop that feeds RPM/PCM clinical outcomes into the Integrated Kidney Care of Florida shared-savings model — turning the fee-for-service program into a documented KCE performance engine.
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: