On January 1, Medicare stopped paying rural health clinics one bundled rate for care management and started paying for each service separately — chronic care management, remote monitoring, and advanced primary care management, each on its own code, each paid on top of the all-inclusive rate. North Caddo's six certified Rural Health Clinics already hold the panel. This is what building the service line around it looks like.
For years, rural health clinics billed care management through a single bundled code, G0511, at one flat rate no matter how much care was delivered. CMS sunset that code on September 30, 2025. Since January 1, 2026, RHCs and FQHCs bill the individual CPT and HCPCS codes at national non-facility rates — and a single patient can carry chronic care management, remote monitoring, and behavioral health integration at the same time, each separately payable on top of the visit.
Care management was a single bundled payment. Doing more for a complex patient than a simple one produced exactly the same revenue, so there was little reason to build depth.
CCM (99490/99439), RPM (99445/99454/99457/99458/99470), and APCM (G0556/G0557/G0558) each bill on their own. Documented time and complexity now translate directly into revenue.
Unbundling multiplies claim volume. At the scale modeled here that is roughly 22,054 individual claims across 24 months — which is precisely why the billing engine, not the clinical protocol, is the part that usually breaks.
CMS added 99445 (device supply for 2–15 days of readings in a 30-day period) and 99470 (10–20 minutes of monitoring management time). The first matters disproportionately in a rural panel: under the old rules a patient who transmitted fewer than 16 days of readings in a month generated nothing at all. Patients who travel, lose power, or lose signal for part of a month are now billable rather than written off. In the model on this page those two codes carry $81,780 of 24-month reimbursement — 17% of all remote-monitoring revenue, from codes that did not exist two years ago.
All six sites are provider-based Rural Health Clinics of the hospital's Medicare certification. Under the current rules, an RHC bills these individual care-management codes at national non-facility rates — separately from, and in addition to, the all-inclusive rate for the visit itself. This is not a reallocation of existing revenue. It is new revenue on top of what the clinics already bill.
Louisiana's local Medicare rates run roughly 7–13% below national rates across this code set. Every figure on this page is modeled at the lower Louisiana rates — so if the national RHC basis applies as expected, the real numbers are approximately 8% higher, and because CoachCare's fees are fixed per patient per month, essentially all of that difference falls to North Caddo. We have deliberately left it out rather than quote you a number we cannot yet tie to a published rate table.
In December 2025 CMS awarded Louisiana $208.4 million in Year 1 Rural Health Transformation Program funding — an estimated $1.4 billion over five years. The Louisiana Department of Health's funded plan names rural health clinics and critical access hospitals as target recipients and explicitly funds remote-monitoring devices, care-coordination technology, and "innovative care models not traditionally billable." LDH committed to CMS on chronic-care outcome measures — blood-pressure and A1c control, and a reduction in potentially preventable emergency visits.
A remote care service line is not merely compatible with that program. It is close to a direct expression of what the state told CMS it would fund — and North Caddo is a critical access hospital operating six rural health clinics in a parish ranked 48th of 64 in Louisiana for health outcomes.
Sub-grant windows are open right now. As of late July 2026, LDH has three application deadlines pending:
August 5 — Rural Collaborative Provider Models · August 7 — Rural Medicaid Alternative Payment Model · August 14 — Regional Care Conveners & Navigation Networks, and Food is Medicine
A Rural Provider VBC/APM Readiness Survey is also live. Deadlines are as published by LDH and move — confirm directly with the Department before relying on any date here.
Critical access hospital and rural health clinic reimbursement is cost-based — for much of what North Caddo does, growing volume also grows the allowable cost base it is paid against. Care management billed at the fee schedule is different. It is separately payable, at a published rate, on top of the all-inclusive rate — one of the few places where new revenue is genuinely incremental margin rather than a larger number on both sides of the ledger. That is the structural reason this service line is worth building even though the clinics are already busy.
Rate basis and policy sources are listed in the Assumptions section at the foot of this page. Certification status verified against the CMS Provider of Services file (Q2 2026). Confirm applicable rates in contracting; RHTP sub-grant terms are set by LDH, not by CoachCare.
North Caddo runs six family-practice sites from the hospital campus on South Pine Street in Vivian out to South Bossier — about 35 miles end to end, across two parishes. That footprint is the organization's greatest strength and the exact reason chronic disease is hard to hold steady between visits.
A hypertensive patient in Oil City is seen a few times a year. In between, nobody sees a blood pressure. Remote care closes that gap without asking the patient to drive: the reading comes to the clinic, a care manager works it, and the patient is only asked to travel when travel is actually the answer.
Straight-line distance from the Vivian hospital campus to South Bossier Medical — the widest point of a six-site footprint.
Ten physicians and eight advanced practice providers across the six clinics, the emergency department, and surgery.
Every clinic is a certified Rural Health Clinic of the hospital — three of them added since 2021, while the regional system next door divested.
Six decades of continuity, and the same chief executive for the last twenty. The relationship that makes enrollment work is already there — that is the hardest part to buy.
These are not our estimates. They are CMS and CDC figures for the two parishes North Caddo's clinics serve.
Caddo Parish standardized Medicare spend runs $15,831 per beneficiary against $12,553 nationally.
274 covered stays per 1,000 beneficiaries against 225 nationally — the gap remote monitoring is built to close.
664 ER visits per 1,000 against 591 nationally. Bossier Parish is higher still at 683.
In Caddo Parish, against 17.2% with diabetes — both well above national rates, and both directly monitorable.
Distances computed from the clinic coordinates published on ncmcla.com (retrieved July 2026); road distance is longer. Clinician roster and founding year as published by North Caddo Medical Center. Utilization figures: CMS Medicare Geographic Variation, CY2024. Chronic disease prevalence: CDC PLACES, 2024 release, crude prevalence among adults 18+. Rural Health Clinic certification verified in the CMS Provider of Services file, Q2 2026.
This model is built on a Medicare panel of 4,000 patients across the six clinics. Nothing here depends on growth, new referral sources, or new service lines — only on serving the panel that already walks through the door.
The starting population across all six family-practice sites.
An estimated 75% carry at least one condition appropriate for remote care. With 44% of Caddo Parish adults hypertensive and 17% diabetic — before adjusting for a Medicare-age panel — this is a conservative read.
Deduplicated across programs — roughly 30% of the in-scope population, reached at a deliberate pace.
RPM 270 · CCM 300 · APCM 600. Many patients carry both monitoring and care management.
All three programs reach their modeled ceilings by month 12 and hold flat thereafter. Fourteen panel-owning providers plus one enrollment specialist fill a 3,000-patient scope inside a year. So the size of this service line is set by the eligible population and the enrollment rates, not by how fast it is staffed. More enrollment capacity reaches the same ceiling sooner — a second specialist is worth roughly $46,000 more over 24 months, with diminishing returns after that — but it cannot raise the ceiling. Confirming a larger eligible population can, and moves the forecast close to proportionally. The Scenario Explorer below lets you test both.
The 4,000-patient panel is a figure supplied for this analysis. It is consistent with the footprint: Caddo and Bossier Parishes hold 75,451 Medicare beneficiaries, so 4,000 is about 5.3% of the two-parish Medicare population — a modest share for the only critical access hospital and six-clinic primary care network in the northern half of that market. The 75% qualifying-condition share is an estimate. Both should be validated against North Caddo's own chart counts and RHC cost-report visit counts before any commitment.
The service line is not three separate programs bolted onto the clinics. It is one enrollment engine, one device and triage operation, and one billing pipeline, serving the same Medicare panel through whichever code fits each patient.
Cellular-connected blood pressure cuffs, scales, and glucometers on the sickest slice of the panel. Readings arrive daily; a care manager works them against protocol.
270 patients at month 24 · $485,961 over 24 months
Monthly non-face-to-face coordination with a comprehensive care plan, for patients carrying two or more chronic conditions. This is the work your nurses already do without being paid for it.
300 patients at month 24 · $607,987 over 24 months
A monthly per-patient payment for longitudinal primary care — no time threshold to document. Built for exactly the population a rural clinic serves.
600 patients at month 24 · $674,813 over 24 months — the largest single line
APCM pays on three tiers, and the top tier exists specifically for Qualified Medicare Beneficiaries — dual-eligible patients with two or more chronic conditions. In Louisiana that tier pays $110.46 per patient per month against $15.49 for the base tier: seven times the rate, for exactly the patients a rural clinic in a high-poverty parish sees most.
And that tier is unusually well populated here. Per CMS enrollment data, 18.1% of Caddo Parish Medicare beneficiaries are QMB — against a national share around 12–13% — with 28.2% dual-eligible overall. Combined with 44% hypertension and 17% diabetes prevalence, a large share of the enrollable panel falls into G0557 or G0558 rather than the base tier.
| APCM tier | Who qualifies | 2026 LA rate / patient / month | Modeled share |
|---|---|---|---|
| G0556 — Tier 1 | One or fewer chronic conditions | $15.49 | 15% |
| G0557 — Tier 2 | Two or more chronic conditions | $50.67 | 55% |
| G0558 — Tier 3 | QMB dual-eligible with two or more chronic conditions | $110.46 | 30% |
| Blended rate at the modeled tier mix | $63.33 | 100% | |
The 15 / 55 / 30 tier mix is an estimate and is the single largest lever on APCM revenue. The modeled 30% Tier-3 share sits above the 16% population-wide QMB share across the two parishes, on the reasoning that enrollment concentrates among the chronically ill, who skew dual-eligible. Your actual QMB counts should be pulled from your own eligibility data before contracting — this assumption moves the largest line in the model in either direction.
Rates shown are 2026 Medicare non-facility rates for the Louisiana locality (Novitas JH). CCM and APCM are mutually exclusive for the same patient in the same month — patients sit in one or the other, never both.
| Code | Service | Frequency | 2026 LA rate |
|---|---|---|---|
| 99453 | RPM — device setup and patient education | Once per episode | $19.26 |
| 99445 New 2026 | RPM — device supply, 2–15 days of readings | Monthly | $46.14 |
| 99454 | RPM — device supply, 16+ days of readings | Monthly | $46.14 |
| 99470 New 2026 | RPM — monitoring management, 10–20 minutes | Monthly | $24.30 |
| 99457 | RPM — treatment management, first 20 minutes | Monthly | $48.26 |
| 99458 | RPM — treatment management, each additional 20 minutes | Monthly | $39.09 |
| 99490 | CCM — first 20 minutes, two or more chronic conditions | Monthly | $62.54 |
| 99439 | CCM — each additional 20 minutes | Monthly | $47.45 |
| G0556 / G0557 / G0558 | APCM — advanced primary care management, by tier | Monthly | $15.49 / $50.67 / $110.46 |
Rates are locality-specific and change annually. All six North Caddo clinics are certified provider-based Rural Health Clinics, so these services should be paid at national non-facility rates rather than the Louisiana locality rates shown above — which run 7–13% lower across this code set. That difference is deliberately not included in any figure on this page; the model uses the more conservative Louisiana basis throughout. Confirm the applicable rate basis in contracting.
A CoachCare-funded enrollment specialist works on site, plus telephonic outreach. Consent, education, and device fitting are ours.
Cellular-connected devices shipped, activated, and replaced. No clinic Wi-Fi dependency, no patient smartphone required.
Health coaches review readings daily against protocol and escalate by the rules in the next section. 9,904 hours over 24 months — about 4.8 full-time equivalents your clinics do not hire.
Your providers keep every clinical decision, order, and care-plan approval. The escalation routes to your team — the labor around it does not.
The on-site enrollment specialist is staffed at CoachCare's expense. It is embedded value in this arrangement, not a cost carried by North Caddo, and is never deducted from the margin shown on this page.
The 2026 unbundling created a billing problem before it created a revenue opportunity: roughly 22,000 individual claims over 24 months, each tied to documented time on a specific patient in a specific month. That is where rural programs stall.
CoachCare is the only care management application integrated with Veradigm Practice Management that creates claims automatically through its own billing engine — eliminating the manual claim-creation step for each patient, every month.
Enrollment flags and trigger ordering by service appear in the workflow your providers already use. Enrollment status is visible in real time — no separate system to learn, no parallel worklist.
Evidence of Care, vitals reports, and care plans attach to the patient's chart monthly. When an audit asks what was delivered, the answer is already in the record — where a reviewer expects it.
Claims generate into Practice Management from the billing engine. This is the difference between a program that scales past a few hundred patients and one that does not.
Patients typically begin receiving services within five days of enrollment. North Caddo runs Veradigm on the clinic side — which is where care-management billing lives — and Oracle Health on the hospital side; the integration described here targets the clinic environment where the program operates. Confirm your Veradigm edition and Practice Management configuration during technical discovery.
Every reading from every program — monitoring, care management, advanced primary care — routes through one escalation engine with one set of rules. Your team sees signal, not noise.
Escalates regardless of symptoms. There is no judgment call and no waiting for a pattern — a critical reading is acted on when it arrives.
Worked through a retake and symptom check first, so a bad cuff placement does not become a phone call to your nurse.
Defined objectively, not impressionistically: three consecutive readings at least an hour apart for blood pressure or glucose, or three readings within seven days for heart rate.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, or sudden swelling: 911 is called with the patient still on the line. If the patient refuses, they are directed to the clinic; if they refuse that, CoachCare activates 911 anyway. This urgent and emergent policy supersedes any client-specific escalation preference — including North Caddo's.
Routed to the specific person North Caddo designates, by clinic site, during defined hours. Not a general inbox.
Documented as an FYI in the chart. No interruption, but a complete trail.
Triggered automatically by any emergency visit or hospitalization in the previous 60 days — the window where rural readmissions are won or lost, and where a 15-bed hospital feels every avoidable return.
Medication reconciliation, red-flag review, confirmation the patient understands what changed.
Symptom and adherence check; follow-up appointment confirmed and barriers to getting there surfaced early.
Stability confirmation and hand-back into the routine monitoring cadence.
Each touch documents and escalates clinical alerts under the same protocol above.
Unreachable patients are pursued on a fixed cadence — voicemail and callback, with escalation proceeding anyway if the value was critical or part of a trend. If a patient cannot be reached, the clinic is notified and the case re-escalates every 30 days rather than quietly lapsing. Every escalation documents the vital, the findings, the contact method, who was reached, the outcome, and the follow-up. The practice is notified at every decision point.
Built from North Caddo's published footprint, a 4,000-patient Medicare panel, and 2026 Louisiana Medicare rates. Enrollment begins in month 1. The programs reach their modeled ceilings by month 12.
| Financial summary | Year 1 | Year 2 | 24-month |
|---|---|---|---|
| Net reimbursement | $682,953 | $1,085,808 | $1,768,761 |
| CoachCare fees (incl. setup & integration) | $403,396 | $619,101 | $1,022,497 |
| Net to North Caddo | $279,557 | $466,707 | $746,264 |
| Margin | 40.9% | 43.0% | 42.2% |
| By program · 24 months | Net reimbursement | Fees | Net to NCMC |
|---|---|---|---|
| Remote Patient Monitoring | $485,961 | $282,374 | $203,587 |
| Chronic Care Management | $607,987 | $309,245 | $298,742 |
| Advanced Primary Care Mgmt | $674,813 | $379,428 | $295,385 |
| Implementation, integration & enrollment | — | $51,450 | −$51,450 |
| Total | $1,768,761 | $1,022,497 | $746,264 |
Month 1 carries the implementation and integration cost and runs slightly negative (−$3,545); the program is net-positive from month 2 onward and every month thereafter. The on-site enrollment specialist is CoachCare's expense and is not deducted above.
Over 24 months — roughly $542,600 in avoided admission cost, against a parish that runs 22% more inpatient stays per 1,000 beneficiaries than the national rate.
About 4.8 full-time equivalents of enrollment, monitoring, and care-management labor CoachCare supplies — in a market where hiring nurses is the binding constraint.
Blood pressures, weights, and glucose values that would otherwise not exist between visits — and that make the chronic-disease conversation concrete.
Created automatically through the Veradigm Practice Management integration rather than keyed by hand, patient by patient, month by month.
Avoided hospitalizations are modeled from remote-monitoring patient-months using the analysis's standard assumption and valued at $15,000 each; they are an estimate of program effect, not a guarantee. All figures on this page are illustrative and modeled — verify against North Caddo's own data.
The model above is one set of assumptions. Move them and watch the whole 24-month picture recalculate — this runs the same enrollment engine as the Value Analysis, calibrated to North Caddo's own rates.
Hospitalizations avoided under this scenario: ~0 over 24 months.
The explorer reproduces the Value Analysis exactly at the modeled settings. It holds pricing, per-program eligibility, attrition, and the enrollment ramp constant, so it shows the shape of the sensitivity rather than a re-quoted price.
Pull the real Medicare panel, the chronic-condition counts, and the dual-eligible and QMB share. Confirm the certification status that sets your rate basis. Every figure on this page gets replaced with one of yours.
Integration build and validation: enrollment flags, chart-attached documentation, and automated claim creation into Practice Management. Escalation routing defined per clinic site.
Launch at one or two clinics — Vivian and one satellite — with the on-site enrollment specialist. Prove the workflow, the escalation path, and the first clean claims before scaling.
Roll out to the remaining sites on the schedule your providers set. The model reaches its enrollment ceilings around month 12; the pace is a choice, not a constraint.
Remote care programs fail on operations, not on clinical intent. This is the operating history behind the model on this page.
Across more than 400 managed conditions.
Clinicians committed to remote care excellence.
Successful in-market program launches.
Care plan coding and billing generating over five million claims.
At a scale that makes protocol, not improvisation, possible.
Enabled across the patient population.
Everything behind the numbers, including what we could not verify.
The headline figure of 900 unique patients is deduplicated. Chronic care management and advanced primary care management are mutually exclusive per patient per month, so their cohorts are distinct patients (300 + 600 = 900). Remote monitoring enrolls within those cohorts rather than adding to them — all 270 monitoring patients are already counted, representing depth on the sickest slice rather than additional breadth.
The enrollment chart and the Scenario Explorer show 1,170 active program enrollments — the sum of all program censuses, which counts a dual-enrolled patient more than once. Both numbers are correct; they measure different things.