Medicare already pays for the care between visits. This is how UnityPoint Clinic bills more of it: today’s vendor-managed CCM and RPM patients carried onto one Epic-first platform with a staffed CoachCare care team while UnityPoint’s own team keeps its highest-risk patients, then new enrollment across 662 providers in 101 Family and Internal Medicine clinics, billed under UnityPoint’s own NPIs.
Medicare is changing what it pays primary care for. Four shifts are under way at once, and each one lands in the same place: the weeks between a patient’s visits. For a system that already carries total-cost accountability through its ACO, those weeks decide how the year goes.
CMS has proposed repricing the remote-monitoring device-supply codes for 2027. The headline cut is large; what it does to a service line is smaller, because device supply is only part of the remote-monitoring month and remote monitoring is only part of the line. Repriced on this forecast’s own billing mix at the Iowa locality, the new-enrollment layer reads like this:
| Code | What it pays for | CY2026 | CY2027 proposed | Change |
|---|
UnityPoint Health runs 18 regional hospitals, 17 community network hospitals and more than 420 clinics, with 1,140 employed physicians and more than a million unique clinic patients a year. Its primary-care CCM and RPM program covers 101 Family and Internal Medicine clinics and 662 providers in Iowa and Illinois, with 11,359 patients enrolled today. UnityPoint names its strengths plainly: a strong patient experience, positive outcomes and established workflows.
The program in scope is the employed primary-care network: Family and Internal Medicine in Iowa and Illinois. UnityPoint’s own interdisciplinary team manages its highest-risk CCM patients; a vendor team manages rising-risk CCM and remote monitoring for the rest.
UnityPoint names them: a strong patient experience, positive outcomes and established workflows. Its own team keeps ordering, provider relationships, oversight and the highest-risk patients. This plan carries the rest over without a gap and builds from there.
UnityPoint Accountable Care scored 87.6 on Controlling High Blood Pressure in PY2024, against a Shared Savings Program mean of 79.49 (CMS). Diabetes poor control ran 7.91 against 9.44, where lower is better. The service line’s job is to hold those numbers as the panel grows.
UnityPoint’s own counts: about 11% of CCM-eligible and 6% of RPM-eligible patients are enrolled today. The program reaches 57% of the patients it tries; 23% of those reached enroll in CCM and 18% in RPM. Reach, follow-up and provider workflow are where the next patients come from.
This is not a cold start. CoachCare already supports UnityPoint patients and clinic teams in three markets. The device logistics, the escalation routes and the people on both sides already know each other, which is why the plan starts its first wave in the Des Moines metro.
UnityPoint has taken on Medicare risk earlier than most systems its size. Click through the years. The next step puts the time between visits on one platform for the whole primary-care network.
Each part of UnityPoint touches a patient at one moment: a clinic visit, a wellness visit, a cardiology referral, a discharge, an episode at home. A remote care service line connects them, so a patient who leaves one is still being watched until the next. Select any part of the system to see what changes.
UnityPoint keeps what it does best: ordering, provider relationships, oversight and care management for its highest-risk patients. CoachCare runs managed CCM for rising-risk patients and RPM in the model UnityPoint picks. Documentation and data land in the permanent Epic record, and a monthly billing file runs through UnityPoint’s own billing systems.
UnityPoint’s centralized nurse care managers already find eligible patients in Epic reports and pend orders for PCP signature. The service line plugs into that, not around it: rising-risk patients with hypertension, diabetes, heart failure, COPD or asthma, or several chronic conditions surface on the same worklist, and UnityPoint keeps the ordering.
Example criteria. UnityPoint’s clinicians set and own the flag logic for each condition, and UnityPoint’s own team decides which patients it keeps.
Epic-first, as UnityPoint defines it, means the documentation and data live in the permanent record within normal Epic workflows. CoachCare’s care team works in CoachCare’s platform and does not need Epic access; its notes, readings, consent and time records interface into the chart. Providers need no second login, and patients see one record in MyUnityPoint.
UnityPoint’s nurses pend the order from Epic reports and the PCP signs it, as they do today.
Cellular devices send readings to CoachCare, and the readings interface into the patient’s Epic record.
Care-plan updates, monthly notes, consent and time records interface into Epic, where they are auditable.
A confirmed trend goes to the PCP clinic’s clinical support team by the route UnityPoint sets, with readings and a recommended next step.
Qualifying patients and codes go to UnityPoint as a monthly billing file routed through its own billing systems. UnityPoint keeps billing.
There is no separate CoachCare portal. What the program interfaces into the permanent Epic record is visible in MyUnityPoint under UnityPoint’s own release rules, so the patient’s record stays complete in one place.
The Epic interfaces are scoped and tested before the first wave and serve all 101 clinics after it. UnityPoint plans Compass Rose for CCM and TCM from 2027, and the interface design is scoped with that plan in mind.
CoachCare Epic integration overview (PDF)Patients enter from a clinic visit or a UnityPoint worklist, after a hospital stay, or by carrying over from today’s program. Every path lands in the same monthly loop: clinic visits, care management and home readings, each one informing the next.
BP 162/96 on three agents and an A1c above 9. A UnityPoint nurse pends the order from the worklist and the PCP signs it in Epic.
Cellular cuff and glucometer at home, a welcome call from the assigned care manager, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the CCM call covers the other conditions.
99454 · 99457 · 99490Clinic visits ↻ care management ↻ home readings.
Flagged in Epic before the patient leaves. Devices ordered to the home.
UnityPoint’s team makes the transitional-care call and visit, as it does today.
TCM, by UnityPointReadings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99457Patients with two or more chronic conditions move into monthly care management.
The market’s vendor-managed patients, programs and care plans are listed with UnityPoint, and consent is reviewed.
Today’s UnityPoint-owned devices lose their data feed at transition, so CoachCare cellular devices ship ahead of go-live and readings do not lapse.
The assigned care manager calls, confirms the routine and the care plan, and the patient’s month continues without a gap.
99454 · 99457 · 99490Same patient, same provider, one platform.
Vendor-managed patients carried over market by market in six waves, each keeping its provider and its care plan. UnityPoint’s own team keeps its 2,219 highest-risk CCM patients. Continuity for current participants is the first measure of success.
The PCP signs the order UnityPoint’s nurses pend, and a CoachCare enrollment specialist reaches the patient by phone or in the clinic.
Cellular scale, glucometer, blood-pressure cuff or pulse oximeter, ready to use, with nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. Language access is scoped with UnityPoint before launch.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in Epic to the first billable day of service. Enrollment status is visible in the chart the whole way through, in every market.
Readings that settle are logged in the chart and visible to the provider without paging anyone.
Out-of-range readings get a retake and a symptom check first. A confirmed trend goes to the PCP clinic’s clinical support team by the route UnityPoint sets, with the readings and a recommended next step. The note interfaces into the chart.
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 clinic. A critical reading on its own goes to the clinic. This cannot be configured away.
CoachCare’s care team works Monday to Friday, 8:00 AM to 5:00 PM in the patient’s local time. Nights, weekends and holidays stay with UnityPoint’s own on-call medical coverage, and patients call 911 in an emergency.
Reporting mirrors the measures UnityPoint already runs the program on: its executive KPIs, its patient-experience measures and its three monthly financials, at provider level where it helps. Insight first; the forecast in chapter 04 is a planning frame.
UnityPoint keeps billing. CoachCare does the identification work behind it.
Enrollment growth and conversion, retention, reach, and the three monthly financials: gross estimated revenue, vendor costs and estimated net contribution. Sample at the modeled month-12 census:
The same platform, Epic interfaces and devices support three ways to staff the program, and UnityPoint can move between them in phases. Each card shows a full year at steady state, at Iowa’s CY2026 rates and UnityPoint’s pricing mix (45% CCM only, 45% both, 10% RPM only). Pick a program size.
| A year at 10,000 patients | Managed | Hybrid | Self Service |
|---|
UnityPoint could award the two programs separately. We recommend keeping them together, because for a patient on both, the readings are what make the monthly care-management work effective, and 4,249 of today’s vendor-managed patients are on both.
The care manager opens the monthly call with weeks of home blood pressure, weight, glucose or oxygen readings, and sets medication changes and goals against them.
A weight gain in a heart-failure patient or a run of high readings triggers outreach, a care-plan update and coordination with the clinic, by the care manager who knows the patient.
The care manager knows the medication list, recent visits, social needs and goals, so an out-of-range reading is triaged as part of a person, not an isolated alert.
One person calls the patient, the clinic gets one escalation path, and there is one record of time, consent and documentation. Two vendors would mean two care teams and two documentation streams.
CMS allows RPM and CCM in the same month when time is not counted twice. One platform keeps one time log for both, so no minute is claimed twice.
Iowa CY2026 rates, the forecast’s own completion rates and net-collection assumptions.
$13.65 more to UnityPoint per dual patient-month, compared against the same two programs on CoachCare pricing: about $696,000 a year across today’s 4,249 dual-enrolled vendor-managed patients.
An optional extension. Medicare fee-for-service and Medicare Advantage are the focus of this program. The same platform and devices can serve UnityPoint’s other patients too, with the operating model matched to how each population is paid: a hybrid by payer.
The CoachCare care team runs rising-risk CCM and RPM monitoring; UnityPoint’s own team keeps its highest-risk patients. The CCM and RPM codes pay for the care-management time, so the staffed team funds itself.
UnityPoint nurses and care managers work in the CoachCare platform with CoachCare devices. Coverage of these services varies by plan and state program, so this runs on Self Service pricing: $5 per patient per month for software and $10 per active device.
UnityPoint at Home clinicians use the same platform and devices. Home health is paid per episode of care rather than per RPM code, so this too runs on Self Service pricing: $5 per patient and $10 per active device.
A phased transition, the way UnityPoint asked for it. Kickoff in January 2027, Epic interfaces built and tested through March, then one market a month from April. Each wave moves that market’s vendor-managed patients onto the new platform with new cellular devices before the next one starts. Continuity for current participants is the first measure of success.
Waves 2 to 6 cover Cedar Rapids, Quad Cities (Iowa and Illinois), Waterloo, Dubuque, Sioux City, Fort Dodge, Marshalltown, Grinnell and Anamosa, in an order UnityPoint sets.
A 36-month planning frame in two layers: today’s vendor-managed patients carried onto CoachCare, and new enrollment from the eligible patients the program has not reached yet. UnityPoint’s own team and its 2,219 highest-risk patients are outside these figures. Both layers are priced at Iowa’s CY2026 Medicare rates with every patient at the Medicare amount, alongside what the program does for patients and for the people who run it.
Four clinic visits a year leave 361 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.
Hypertension is the most common condition in a Medicare primary-care panel and the one 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 clinic reading.
Cardiac Solutions, a physician-owned cardiology practice, put 2,738 patients on CoachCare remote monitoring with home blood-pressure readings.
UnityPoint Accountable Care is scored every year on a fixed set of quality measures, and it beats the Shared Savings Program average on the two most tied to this program. Select a measure to see how the work supports it.
Watching the panel every day tells a clinic who needs to be seen now, not only who is next on the schedule. Patients surface from their home data, not only when they come in sicker.
When a UnityPoint patient goes home from the hospital, the next 30 days decide whether they come back. UnityPoint’s team handles transitional care; post-discharge monitoring watches the month, and chronic care management carries the patient past it.
Flagged in Epic for post-discharge monitoring.
UnityPoint’s transitional-care call and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly care management, with RPM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, and a cardiology referral when the trend returns.
Oxygen saturation and symptoms after an exacerbation, with a quick visit before a return trip to the emergency department.
Glucose and BP while medications change after a stay, and a fluid check for patients with CKD.
After the first month, patients with two or more chronic conditions move into monthly CCM with the same care manager, so the discharge starts a relationship rather than ending an episode.
Every code the service line can bill, at CY2026 Medicare rates for Iowa. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Iowa locality 00 (WPS, MAC 05102). Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill per patient per month. About 47.4% of Medicare beneficiaries in UnityPoint’s 13 counties are in Medicare Advantage. Those plans must pay at least the Medicare rate, a floor; individual contracts set their own terms for the care-management code families, and the forecast prices every patient at the Medicare amount.
The carried-over layer is the program UnityPoint already runs, moved onto one Epic-first platform with a CoachCare care team. The new-enrollment layer is growth: eligible patients the program has not reached yet. Its reimbursement is largely money the program already bills today; what changes is the platform and the care team behind it. Select a layer to redraw the charts.
| By layer | Year 1 | Year 2 | Year 3 | 36 months |
|---|---|---|---|---|
| Carried over: today’s 9,140 vendor-managed patients | ||||
| Net reimbursement | $11,524,173 | $12,692,670 | $10,587,362 | $34,804,205 |
| CoachCare cost | $6,569,673 | $7,235,807 | $6,035,618 | $19,841,097 |
| Net to UnityPoint | $4,954,501 | $5,456,864 | $4,551,744 | $14,963,109 |
| Margin to UnityPoint | 42.99% | 42.99% | 42.99% | 42.99% |
| New enrollment | ||||
| Net reimbursement | $1,120,434 | $6,995,038 | $13,537,173 | $21,652,646 |
| CoachCare cost (program, Epic and enrollment fees) | $663,925 | $4,038,612 | $7,773,803 | $12,476,340 |
| Net to UnityPoint | $456,509 | $2,956,427 | $5,763,370 | $9,176,306 |
| Margin to UnityPoint | 40.74% | 42.26% | 42.57% | 42.38% |
| Combined service line | ||||
| Net reimbursement | $12,644,607 | $19,687,709 | $24,124,535 | $56,456,851 |
| CoachCare cost | $7,233,598 | $11,274,418 | $13,809,421 | $32,317,437 |
| Net to UnityPoint after fees | $5,411,010 | $8,413,291 | $10,315,114 | $24,139,414 |
| Margin to UnityPoint (net ÷ net reimbursement) | 42.79% | 42.73% | 42.76% | 42.76% |
| New enrollment by program: remote monitoring $7,528,436 · chronic care management $14,124,210 in net reimbursement. On the combined view the service line is net-positive from month 1; the new-enrollment layer alone runs −$4,918 in month 1 while implementation and the Epic setup post, and is net-positive from month 2. Fee-for-service reimbursement only; no shared-savings dollars are in these figures. | ||||
Change the assumptions and the 36-month forecast recalculates. The first five sliders drive the new-enrollment layer; the last one sets how many of today’s patients carry over. UnityPoint’s own Medicare panel by payer and the CCM and RPM split of today’s patients are the first numbers to plug in.
In the managed model CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. Drag the slider to see the team grow with the census, carried-over and new patients together.
UnityPoint’s physicians, advanced practice providers and clinic staff keep doing clinical work. In the managed model the monitoring, outreach and paperwork belong to CoachCare.
Hired, trained and managed by CoachCare. UnityPoint would otherwise need to recruit and keep them.
Monitoring, outreach and documentation over 36 months for new patients, on CoachCare’s payroll.
The enrollment specialist working in UnityPoint clinics and device logistics are CoachCare’s expense.
The staff, protocols and Epic workflow built for remote monitoring and chronic care management can take on the next programs UnityPoint’s patients qualify for, without a second hiring plan or a second build.
APCM pays a monthly amount per patient in place of CCM, tiered by complexity, and UnityPoint Clinic qualifies through its ACO. It is not in this forecast. Moving patients from CCM to APCM is a program decision to make together.
UnityPoint keeps transitional care. The post-discharge pathway hands its patients into monitoring and then CCM, and the forecast counts them only once they enroll. TCM itself is not in this forecast.
UnityPoint at Home could run its remote monitoring on the same platform, devices and Epic interfaces, staffed by its own clinicians. It is an option, not part of this forecast.
Six reasons this partnership fits UnityPoint specifically, not remote care in general.
CoachCare supports remote monitoring for UnityPoint cardiology patients in Cedar Rapids, Waterloo and Des Moines, and for patients of several Des Moines-area Family and Internal Medicine clinics. The first wave starts where the teams already know each other.
Readings, care-plan documentation, consent and time records interface into the permanent Epic record; billing arrives as a monthly file through UnityPoint’s own systems. No second login for providers and no separate patient portal, with the interfaces scoped toward Compass Rose in 2027.
Managed chronic care management for rising-risk patients, the model UnityPoint favors, and remote monitoring managed or technology-enabled, with phased moves between them. CoachCare’s care managers carry 165 patients each, with business-hours alert triage and devices on CoachCare’s payroll and fees per active patient per month.
Ordering, provider relationships, oversight and the highest-risk patients stay with UnityPoint’s own team, and the program’s patient experience, outcomes and workflows carry over. Claims go out under UnityPoint Clinic’s own billing entity and NPIs.
Cellular scales, glucometers, cuffs and pulse oximeters that need no home internet, for a state where more than a third of residents live outside a city. Language access is scoped with UnityPoint, market by market, before the first patient enrolls.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions (case study), half the 30-day readmission rate across 26,689 patients at the same practice (case study), and 74% fewer admissions and 63% fewer emergency visits for chronic-disease patients at Advocate Aurora, on the VitalTech platform, now part of CoachCare.
The ask: a finalist working session to plan continuity for current participants market by market, set the order of the six waves, scope the Epic interfaces and the monthly billing file with UnityPoint’s IT, Coding and Billing teams, and agree where RPM runs managed and where it runs technology-enabled.
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