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.
Month-24 census is ~2,545 active program enrollments (RPM ~1,865 + PCM ~679); the headline patient figure is 2,069 unique patients after de-duplicating those enrolled in both programs.
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 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 one of its nephrologists 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 one of its nephrologists 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 one is a shared-savings lever on top of its CPT line.
A named, governed service line with its own owner and scorecard — not a point solution bolted onto one diagnosis. It follows 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 opens the 2–15-day window |
| 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 |
The value analysis below uses MAC-locality rates auto-resolved for zip 34471 (First Coast Service Options, Florida).
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. The exact Greenway product — Intergy versus Prime Suite — 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 |
| CoachCare program fees | $402,405 | $1,259,156 | $1,661,561 |
| Ancillary & one-time fees | $18,814 | $15,971 | $34,785 |
| Practice margin (after all fees) | $309,089 | $971,013 | $1,280,102 |
| Fees include implementation, Greenway integration, devices, 24/7 monitoring, and enrollment. The on-site enrollment specialist is CoachCare's expense — embedded value that is never subtracted from the practice margin above. | |||
24-month practice margin: 43.0% of net reimbursement (Year 1 42.3%, Year 2 43.2%).
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).
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 running remote care programs day to day.
Successful program implementations.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
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 $760,237 of the modeled $2,976,447 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 $189,411, RPM accounts for $185,382 and the care-management arm for $4,029.
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 Ocala Kidney Group specifically, not remote care in general.
CoachCare integrates natively with Greenway: enrollment flags and trigger orders leave the EHR, and discrete vitals, care documentation and claim-ready charges come back into the flowsheet. One chart for the nephrologists, one workflow for billing, and no second platform for the team to learn.
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 43.0% margin, with no hiring cycle. On-site enrollment is our expense — telephonic outreach converts about 8%, so we staff the clinic instead.
Your nephrologists 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 practice keeps control of.
Ocala Kidney Group already carries total-cost-of-care exposure through Integrated Kidney Care of Florida. Every RPM reading and PCM touch that slows CKD progression, controls resistant hypertension or prevents a crash-start bills today and moves the number the Kidney Contracting Entity is measured on. One remote care service line covers both the fee capture and the shared-savings math.
There is no existing remote-monitoring vendor to rip out and no parallel workflow to retire. The program is built once, inside Greenway, for the CKD, resistant-hypertension and dialysis-transition panels the practice 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.