In CY2024 your employed clinicians billed 3,914 hospital discharge-day-management services and not one transitional care management claim. On 1 January 2026 CMS started paying you on that exact window.
Maury Regional's safety record is the strongest evidence in your own CMS file. The readmission record is the weakest. Those two facts sit next to each other, and the second one is now a payment problem.
PSI-90 patient-safety composite, with every individual component measure rated No Different Than National.
Every reported HRRP excess readmission ratio at CCN 440073 is above 1.0 — CMS observed more readmissions than expected after risk adjustment.
| HRRP measure | Excess ratio |
|---|---|
| Hip / knee replacement | 1.1263 |
| COPD | 1.0895 |
| Heart attack (AMI) | 1.0784 |
| Heart failure | 1.0140 |
| Pneumonia | 1.0103 |
Excess Days in Acute Care after a heart-failure discharge: +8.8 days per 100 discharges — “More Days Than Average.”
EDAC counts readmissions, emergency department visits and observation stays together across the thirty days after discharge. It is the one measure that captures everything a patient does when they get worse at home and nobody is watching. It is also the measure a transitional-care and monitoring program moves fastest.
We pulled every Medicare Part B line billed by all 145 clinicians employed by Maury Regional Medical Group and Maury Regional Hospital in CY2024 — 202 distinct HCPCS codes, 772 provider-code lines, $7,080,435 in allowed charges. Here is what the care-management column looks like.
| Code family | Clinicians billing | Beneficiaries | Allowed |
|---|---|---|---|
| Hospital discharge day management — 99238, 99239 | 27 | 3,784 | $384,556 |
| Transitional care management — 99495, 99496 | 0 | 0 | $0 |
| Remote physiologic monitoring — 99453, 99454, 99457, 99458 | 0 | 0 | $0 |
| Remote monitoring, CY2026 rungs — 99445, 99470 | 0 | 0 | $0 |
| Chronic care management — 99490, 99439, 99487, 99491 | 0 | 0 | $0 |
| Remote therapeutic monitoring — 98975–98981 | 0 | 0 | $0 |
| Physiologic data review — 99091 | 0 | 0 | $0 |
CMS suppresses any clinician-code line under 11 beneficiaries, so the accurate reading is no care-management program at meaningful scale in CY2024. Part B carrier claims only — your ten FQHC and seven Rural Health Clinic sites bill institutionally and are not visible in this file.
Average HCC risk score across your employed panel, against a national reference of 1.00. Average beneficiary age 75.1.
Hypertension and hyperlipidemia prevalence, both at the CMS reporting ceiling. Diabetes 40.8%, CKD 39.5%, ischemic heart disease 37.2%, heart failure 31.8%, COPD 26.3%.
Medicare discharges across cardiovascular (409), respiratory (209) and renal (225) MS-DRGs — 34% of the hospital's published total. Heart failure with MCC alone is 244, the second-largest DRG in the building.
You have already proven the model works. CardioMEMS went live in May 2025 — an implanted pressure sensor, daily readings from home, your team reviewing them remotely. It reaches your most advanced heart-failure patients. The question is the other 95% of the panel, and the code families that pay for reaching them.
Neither is optional and neither is theoretical. One started in January. The other is yours — you built it.
Maury Regional Hospital, CCN 440073, is a mandatory TEAM participant for the performance period 1 January 2026 through 31 December 2030, in CBSA 34980. Nineteen hospitals from that CBSA appear on the CMS participant list and every one is mandatory — this is a mandatory market, not a voluntary election.
TEAM reconciles all Part A and Part B spending in the thirty days following a qualifying episode. Marshall Medical Center (441309, critical access) and Wayne Medical Center (440780, rural emergency) sit outside TEAM entirely — both are non-IPPS. The exposure is concentrated at Columbia.
ACO A5543 began its first agreement period on 1 January 2025 — BASIC Track Level B, high-revenue, with prospective assignment. Four participant TINs: the hospital, Marshall Medical Center, the medical group, and one independent practice.
Prospective assignment is the detail that matters operationally. You know your assigned beneficiary list on 1 January, so an enrollment campaign has no attribution guesswork — the best possible starting condition. High-revenue status puts the hospital's Part A spend inside the benchmark, so a readmission you prevent lands on your shared-savings math and on your TEAM reconciliation.
The 2026 physician fee schedule added two remote-monitoring codes built for exactly this window: 99445 for a 2–15 day device-supply period and 99470 for 10–19 minutes of treatment management. A patient discharged on a Tuesday can be enrolled, monitored and billed inside the first fortnight, rather than waiting out a 16-day threshold that never fit a post-discharge episode. Together they carry a meaningful share of the forecast below.
The same enrollment, device, triage and billing engine serves the post-discharge cohorts and the employed primary-care panel. You build it once and point it at whichever population is in front of you.
Tennessee, Palmetto GBA carrier 10312, locality 35 — non-facility rates.
| Code | What it pays for | Rate | Cadence |
|---|---|---|---|
| 99495 / 99496 | Transitional care management, moderate / high complexity | — | Once per discharge |
| 99453 | Remote monitoring set-up and patient education | $19.49 | Once per episode |
| 99445 | Device supply, 2–15 days of readings | $47.24 | Monthly |
| 99454 | Device supply, 16+ days of readings | $47.24 | Monthly |
| 99470 | Treatment management, 10–19 minutes | $24.38 | Monthly |
| 99457 | Treatment management, first 20 minutes | $48.42 | Monthly |
| 99458 | Treatment management, each additional 20 minutes | $39.01 | Monthly |
| 99490 | Chronic care management, first 20 minutes | $62.29 | Monthly |
| 99439 | Chronic care management, each additional 20 minutes | $47.35 | Monthly |
A CoachCare enrollment specialist works on site, paid by CoachCare, alongside a telephonic team. Consent, device fitting and the first reading happen without adding a role to your payroll.
Cellular-connected cuffs, scales and pulse oximeters. No patient wi-fi, no app dependency, no pairing step at the kitchen table.
Claims are generated from the documented care actions, so the code that gets billed is the work that was done. Your revenue cycle receives a clean claim, not a coding project.
Every reading — whichever program it came from — routes through one escalation engine. Your team sees signal, not a feed.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling. The care manager calls 911 with the patient still on the line. If the patient refuses, they are directed to the clinic; if they refuse that, CoachCare activates 911 regardless.
A critical reading escalates whether or not the patient has symptoms. Out-of-range readings trigger a retake and a symptom check first. A trend is defined objectively — three readings at least an hour apart for blood pressure or glucose, or three inside seven days for heart rate.
Documented in the record as a notification, not a page. The practice is told at every decision point without being interrupted for events that resolved on the call.
CoachCare's urgent and emergent policy supersedes any client-specific escalation preference. You can route non-critical findings wherever you like — a named clinic contact, a nurse line, the attending. You cannot configure the emergency pathway away, and neither can we.
Any hospitalization or emergency department visit in the last sixty days triggers a fixed three-touch sequence:
Every escalation records the vital, the findings, the contact method, who was reached, the outcome and the follow-up. A patient who cannot be reached gets a voicemail and a callback window, and is escalated anyway if the value is critical or the trend is established. Unreachable patients re-escalate on a fixed cadence rather than falling off a list. This is the same governance that satisfies a Joint Commission heart-failure certification survey.
Modeled on 18,000 Medicare beneficiaries with 11,700 carrying a qualifying chronic condition, 111 referring clinicians, and CY2026 rates at the Tennessee 10312-35 locality. The enrollment specialist is staffed at CoachCare's expense and is not a line in your budget.
| Year 1 | Year 2 | 24 months | |
|---|---|---|---|
| Net reimbursement | $3,503,737 | $6,146,718 | $9,650,455 |
| CoachCare fees | $2,054,823 | $3,518,842 | $5,573,665 |
| Patients under management | 3,452 | 3,452 | 3,452 |
| Hospitalizations avoided | 133 | 213 | 346 |
| Service line net | $1,448,914 | $2,627,876 | $4,076,790 |
| Margin | 41.35% | 42.75% | 42.24% |
Positive in the first month, after implementation and integration setup post.
Monthly service line net from month 13 onward.
Physiologic readings taken, transmitted and clinically reviewed over 24 months.
Billable, documented care-management actions in the record.
41.5 full-time-equivalents of care management, delivered by CoachCare.
At a 20% baseline annual admission rate. On a heart-failure and COPD cohort the realistic figure is closer to 40%.
Both programs hit their ceiling inside year one — remote monitoring in month nine, chronic care management in month twelve — and hold flat through month twenty-four. Your binding constraint is not referral supply or outreach capacity; with 111 referring clinicians you have more of both than the program can absorb. The constraint is how many patients you decide are in scope. Widening the in-scope population from 11,700 to 14,000 moves the twenty-four-month forecast 14%. That is the first number to settle, and it is settled from your own chart counts, not from ours.
This runs the same enrollment engine as the Value Analysis above. At the modeled settings it reproduces the workbook exactly.
Your chart counts replace our estimate of the in-scope panel, and we split it between the practices that bill on the fee schedule and the FQHC and Rural Health Clinic sites, which price care management on a different rail.
We confirm your current EHR and the interface path, then scope enrollment flags, discrete vitals into the chart, and claim generation. Nothing about the program lives in a second system your clinicians have to learn.
Heart failure and COPD discharges first — the cohorts carrying both the readmission ratios and the TEAM episodes. Transitional care management from day one, monitoring from the first week at home.
The same engine turns to the ACO's assigned panel in January, when the prospective list lands. One enrollment, device, triage and billing operation, pointed at whichever population is in front of it.
Across more than 400 managed conditions
Running remote care programs day to day
Programs stood up and running in market
Care-plan coding and billing behind them
And 4 million-plus care actions enabled