Texas Primary Care Specialists already runs remote monitoring with CoachCare for 22 Medicare patients. This is the same service line taken across the rest of the practice’s Medicare panel, billed under your own NPIs and run by a CoachCare care team inside eClinicalWorks.
Medicare is changing what it pays primary care for. Four shifts are under way at once, and each one lands in the weeks between a patient’s visits. Texas Primary Care Specialists already covers those weeks for 22 patients. The question now is the rest of the panel.
Texas Primary Care Specialists is an independent, physician-owned adult primary care practice in Frisco, founded in 2013. Six adult primary care clinicians (three internal medicine physicians, two family nurse practitioners and one physician assistant) see patients on one eClinicalWorks system, and the practice draws labs in-house and sees walk-in patients. Its traditional-Medicare patients average 73 years old and carry a CMS risk score of 1.01. At least three in four have hypertension and 39% have diabetes. Since 2025 the practice has run remote monitoring with CoachCare, and 22 Medicare patients are on the program today.
An older Medicare panel, average age 73, in which high blood pressure and high cholesterol are the norm and 39% of patients have diabetes.
CMS reports hypertension at 75% or more of the practice’s traditional-Medicare patients. Home readings catch what one office reading misses and let the care team adjust medication month to month instead of at the next visit.
39% of the practice’s traditional-Medicare patients have diabetes, and most of them also carry hypertension. Glucose and blood pressure readings from home give the care team a reason to call before the next A1c comes back high.
22% have chronic kidney disease, 27% ischemic heart disease, 17% atrial fibrillation and 15% heart failure. Daily weight and blood pressure show fluid building days before breathlessness brings a patient to an emergency department.
Each step below added clinicians, services or a new way of caring for patients between visits. Click through the years. The next step takes remote monitoring from a small group of patients to the whole eligible panel.
Each part of the practice touches a patient at one moment: an office visit, a wellness visit, a lab draw, a walk-in visit, a hospital discharge. Remote monitoring connects them, so a patient who leaves one visit is still being watched until the next. Select any part of the practice to see what changes.
The practice’s clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program, as it does for today’s patients. Everything runs through the eClinicalWorks system the practice already uses, from the first flag on a patient’s chart to the claim at month end.
Growth starts with the panel, not a referral pad. eClinicalWorks already holds the diagnoses, vitals, labs and medications. Patients who qualify for remote monitoring and are not yet enrolled are flagged, highest risk first, using criteria the practice’s clinicians set, so they surface at a chronic-care visit, a wellness visit, a walk-in visit or after a discharge.
Example criteria. The practice’s clinicians set and own the flag logic for each condition.
New patients enter at an office visit or after a hospital stay, the same way today’s patients did. Either way they land in the same monthly loop: office visits, care-team calls and readings from home, each one informing the next.
Select a patient to open the example; select it again to close it.
Type 2 diabetes with an A1c of 8.3, and BP 148/88 on two agents. The clinician places the remote care order before checkout.
Cellular glucometer and BP cuff at home, a welcome call by phone, and a morning routine: check glucose, then take a reading.
99453Fasting glucose trends guide diabetes medication between visits; home BP averages guide the blood pressure plan.
99454 · 99457Office visits ↻ care-team calls ↻ readings from home.
Flagged in eClinicalWorks when the discharge notice arrives. Scale and cuff ordered to the home.
The practice calls the patient and books the follow-up visit, as it does today.
Readings start right away. The short-month device code covers the first partial month.
99453 · 99445Office visits ↻ care-team calls ↻ readings from home.
CKD stage 3b, eGFR down from 44 to 38, office BP 154/90 on two agents. The clinician orders home BP monitoring at the visit.
Cellular BP cuff at home and a welcome call on how to take a reading that counts.
99453Home averages drive dose changes, and the in-house lab draws the kidney panel that follows each change.
99454 · 99457Office visits ↻ care-team calls ↻ readings from home.
The clinician orders from the chart, or a CoachCare enrollment specialist enrolls the patient during the visit.
Cellular devices arrive ready to use. The patient needs no Wi-Fi, smartphone or home internet, and has nothing to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The routine is set to fit the patient’s day.
Readings reviewed, calls logged, escalations routed. It repeats every month.
From the enrollment flag in eClinicalWorks to the first billable day of service. Enrollment status is visible in the chart the whole way through.
Readings that settle are logged in the chart and visible to the clinician without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the clinician or nurse the practice designates, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath or stroke signs reported on a call: the care team calls 911 with the patient on the line, then notifies the practice. A critical reading on its own goes to the practice. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for the practice’s leadership, and a clinical outcomes report for the clinicians.
CoachCare is the only care-management application integrated with eClinicalWorks that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the practice. Sample below at the modeled month-12 census.
A 24-month forecast for remote monitoring across the practice’s Medicare panel: the 22 patients enrolled today plus new enrollment from the patients who qualify and are not yet on the program, on traditional Medicare and Medicare Advantage, priced at CY2026 Medicare rates for the Rest of Texas locality.
Two chronic-care visits a year leave 363 days with no data. RPM bills only when a patient takes readings on at least 16 days in a month, so an enrolled patient gives the care team at least 192 days of readings a year.
At least three in four of the practice’s Medicare patients carry hypertension, and it is the condition home monitoring moves fastest. Home averages give the care team a monthly reason to adjust medication, and the documented result is the home number, not one rushed office reading.
Cardiac Solutions, a physician-owned cardiology practice with three West Phoenix offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
Readings from home tell the practice which patients need a visit now, whatever the schedule says. Patients surface from their home data instead of coming in sicker.
The 30 days after a hospital stay decide whether a patient comes back. Remote monitoring starts within days of discharge and carries the patient through that window and past it.
Flagged in eClinicalWorks for post-discharge monitoring.
The practice calls and books the follow-up visit.
Readings start right away. 99445 bills the short first month.
Monthly RPM for as long as it helps the patient.
Daily weight and BP from day two, a call on any gain of 2 to 3 lb, and a cardiology referral when the trend returns.
Blood pressure while medications change after a stay, and a kidney lab drawn in-house after each dose change.
Glucose while the hospital’s insulin plan becomes the home plan, with a call on any low.
Every remote monitoring code the service line bills, at CY2026 Medicare rates for the Rest of Texas locality, which covers Frisco. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Rest of Texas locality 99 (Novitas Solutions, MAC 04412). Frisco is in this locality, not the Dallas one. Only one device code (99454 or 99445) and one first-tier management code (99457 or 99470) bill for a patient in a given month. About 45% of Denton County’s Medicare beneficiaries are in Medicare Advantage. Those plans cover these Part B services and pay them on each plan’s own contract terms; the forecast prices every patient at the Medicare amount.
The 22 patients enrolled today stay on the program, and new enrollment reaches the rest of the eligible panel. Contribution margin runs −$5,037 in month 1 while new enrollment ramps; positive from month 2.
| Remote monitoring, full panel | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Patients enrolled, end of period | 61 | 57 | 57 |
| Contribution margin | $25,130 | $31,197 | $56,327 |
Change the assumptions and the 24-month forecast recalculates. New enrollment fills the eligible panel by month 3, so the binding constraint is the size of the panel, not enrollment pace. The practice’s own Medicare chart count is the first number to plug in.
CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. The full eligible panel fits inside one care manager’s caseload. Drag the slider to follow the census.
The practice’s physicians, nurse practitioners, physician assistant and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare, for new patients exactly as for today’s.
Monitored, called and documented by CoachCare’s care team, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. The practice would otherwise need to recruit and keep one.
The enrollment specialist working in the practice and the device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system the practice already runs, using its built-in workflows. Clinicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
eClinicalWorks integration overviewThe practice already runs remote monitoring, draws labs in the building and sees walk-in patients. CoachCare adds patients to the program it already runs, and each part of the practice keeps the work it does today.
The 22 patients on remote monitoring keep their devices, their routine and their monthly calls. New patients join the same program beside them.
A1c, kidney panels and lipids are drawn in the building. When home readings call for a dose change, the lab that follows it can happen at the next stop by the office.
A Medicare patient who walks in with a high blood pressure reading or new swelling can leave with a device order, and the care team calls within days.
Six reasons this fits Texas Primary Care Specialists specifically, not remote care in general.
The practice has run remote monitoring with CoachCare since 2025. Growing it puts more patients on a program the clinicians, the billing team and today’s patients already know. Nobody has to learn a new vendor or a new workflow.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible to every clinician.
CoachCare’s care managers carry the caseload at 165 patients each. Enrollment, devices, business-hours alert triage and billing preparation are on CoachCare’s payroll, with no capital outlay.
The practice’s clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under the practice’s own billing entity and NPIs.
The practice’s traditional-Medicare patients average 73. Cellular devices need no home internet, smartphone or pairing, and outreach runs by phone, so no patient has to learn an app.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions in West Phoenix (case study), half the 30-day readmission rate across 26,689 patients at the same practice (case study), and zero readmissions among 450 advanced heart-failure patients at Iowa Heart (case study).
The ask: a working session with the practice’s physician leadership and operations team to confirm the Medicare chart count by payer, agree which patients are offered remote monitoring first, scope the eClinicalWorks integration, and set the date new enrollment begins.
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