Kidney function doesn't decline on a quarterly schedule. How Houston Nephrology Group can wrap continuous remote monitoring and principal care management around CKD progression, resistant hypertension, dialysis planning, and transplant-list stability — and get paid for it, starting now.
Month-24 census is 492 active program enrollments (RPM 250 + PCM 242); the headline patient figure is 322 unique patients after de-duplicating those enrolled in both programs. All figures illustrative, modeled — verify against practice data.
This is not a turnaround story. Houston Nephrology Group is an independent, physician-owned practice that has served greater Houston for more than four decades, with full-spectrum kidney care across four offices from Memorial City to Katy, Cypress, and Willowbrook. The strategic question is what happens to those patients in the weeks between visits — and who gets paid for managing it.
A physician-owned P.A. with clinicians and advanced-practice staff covering the Memorial City, Katy, Cypress/290, and Willowbrook corridors.
CKD management, dialysis management, vascular access, kidney biopsy, critical care nephrology, hypertension, and transplant care — the complete clinical scope a remote care layer plugs into.
The Memorial City flagship office sits in the Medical Plaza adjacent to Memorial Hermann Memorial City Medical Center — discharge volume and follow-up flow through the same campus.
The practice already runs a cloud eClinicalWorks instance with an active patient portal — the digital substrate a remote care program integrates with directly.
What's missing is the service line itself: no remote patient monitoring, chronic care management, or principal care management program is marketed anywhere on the practice's site today. The patients, the clinical scope, and the infrastructure are in place — the interstitial care layer, and the recurring revenue attached to it, are not.
Three forces converge in 2026: kidney disease progresses between appointments, Medicare now pays for managing that interval, and the economics stand on their own fee-for-service footing — no external program participation required.
A CKD 3b–5 patient is typically seen quarterly — but blood pressure drift, fluid shifts, and medication problems unfold week by week. An unplanned, in-hospital "crash" dialysis start is the most expensive single event in kidney care, and most crash starts announce themselves in data no one is watching. Daily BP and weight telemetry closes exactly that gap.
New CY2026 codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) remove the old 16-day floor — post-hospitalization surveillance, medication-change windows, and pre-dialysis intensification periods become cleanly billable alongside the established RPM and PCM code families.
Every dollar in this analysis is ordinary Medicare fee-for-service billing — margin-positive on its own, with no dependence on any value-based arrangement. And as kidney care moves toward accountability for total cost, the practice that already runs continuous monitoring, documented interventions, and planned-start pathways holds the strongest possible negotiating position, whatever it chooses next.
Not a gadget program bolted onto one diagnosis — a named service line with its own P&L, run on CoachCare's engine and governed by Houston Nephrology Group's physicians, following the kidney patient across all four offices.
| Service | Codes | ~CY2026 Magnitude | Nephrology Use |
|---|---|---|---|
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · $51.87/mo | Daily BP/weight telemetry; 99445 unlocks 2–15-day post-discharge and titration windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $52.23 + add'l units | Monthly review, medication adjustment, escalation per practice protocol |
| Principal Care Management | 99426 · 99427 | $68.73 + $54.73 add'l | Monthly management of CKD as the dominant condition, ≥30 min clinical staff time |
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every kidney-related hospitalization discharge |
Dollar figures shown for 99454, 99457, 99426, and 99427 are the CY2026 Physician Fee Schedule amounts auto-resolved for the practice's Houston locality (Novitas, ZIP 77024); others are illustrative national magnitudes. Verify against the current fee schedule.
The same infrastructure — enrollment, devices, alerts, navigation, documentation, billing — compounds across four distinct layers of practice value. The first one pays for all the rest.
Houston Nephrology Group already operates a cloud eClinicalWorks environment with an active patient portal. CoachCare integrates with eClinicalWorks bi-directionally — enrollment, vitals, documentation, and claims flow between the platform and the chart, so clinicians work where they already work.
Catalog eClinicalWorks integration pricing — one-time setup, monthly maintenance, and per-patient fee. Already included in the modeled CoachCare fees below.
The practice's exact eClinicalWorks product and version are validated during contracting, and the integration is configured before the first patient enrolls.
A 24-month forecast for the RPM + PCM service line: an estimated 950-patient Medicare panel across ~9 referring clinicians, one on-site enrollment specialist at CoachCare's expense, CY2026 rates auto-resolved for the practice's Houston locality, and eClinicalWorks integration fees included. Avoided-hospitalization savings and transitional care billing are not in these numbers — they are upside on top. All figures are illustrative, modeled — verify against practice data.
| Program | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $208,082 | $290,320 | $498,402 |
| PCM net reimbursement | $109,436 | $265,346 | $374,782 |
| Total net reimbursement | $317,518 | $555,666 | $873,184 |
| CoachCare program fees | $171,174 | $301,020 | $472,194 |
| Ancillary & one-time fees | $16,906 | $8,878 | $25,784 |
| Practice margin (after all fees) | $129,437 | $245,769 | $375,206 |
| Includes an on-site enrollment specialist staffed at 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 40.8%, Year 2 44.2%). Illustrative, modeled — verify against practice data.
Figures are illustrative, modeled — verify against practice data. Values are rounded to the nearest dollar, so row and column sums may differ by $1. 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.
≈ $509K in avoided acute cost at $15K per admission — modeled separately from the revenue above.
~7,896 hours of monitoring, outreach, and documentation handled by the service line, not the practice's staff.
CoachCare operates as the service line's engine — enrollment outreach, device logistics, 24/7 monitoring, and billing-ready documentation — while Houston Nephrology Group's physicians govern protocols and every clinical decision. Full-service delivery means launch requires no new practice headcount; the practice's role is protocol sign-off, escalation response, and monthly review of a one-page scorecard.
Named physician champion and scorecard; eClinicalWorks integration and billing configuration; protocol sign-off for CKD-progression, resistant-hypertension, and volume-management pathways; panel validation against actual chart counts.
Two anchor cohorts — CKD 3b–5 patients approaching modality decisions, and the resistant-hypertension panel — enrolled at the flagship office with on-site enrollment support.
Katy, Cypress/290, and Willowbrook enrolling on the same protocols and the same eClinicalWorks build; monthly scorecard review of census, capture rate, and revenue per patient-month.
Planned-start pathway live (telemetry-triggered access and modality planning); PCM reaching its 242-enrollment ceiling in month 15 with RPM already at 250; transplant-list stability cohort monitored; structured monitoring summaries flowing to referring PCPs as the referral-durability layer.
The flagship office at 915 Gessner Road sits in Medical Plaza III, adjacent to Memorial Hermann Memorial City Medical Center — so the practice's highest-acuity discharges, its densest physician coverage, and its administrative home base all sit within one campus loop, on one eClinicalWorks instance.
A Memorial City–first launch concentrates enrollment where volume already flows, lets one office's physicians and staff shake out the workflow, and produces the internal evidence — census, capture rate, revenue per patient-month, admission signal — that makes the four-office rollout a data decision, not a leap.
| Milestone | Target |
|---|---|
| eClinicalWorks integration + protocol sign-off | Day 30 |
| First billable enrollments | Day 30–45 |
| 48-hour post-discharge outreach rate | ≥ 90% |
| Reading-compliance rate (16+ days/mo) | ≥ 75% |
| Active program enrollments by Day 90* | ~103 |
| Go / scale decision with full unit economics | Day 90 |
*The modeled months 1–3 practice-wide census (21 → 55 → 103 active enrollments), concentrated at the pilot office during the Memorial City–first phase. Illustrative — the pilot's actual funnel is set in protocol design.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers committed to remote care excellence.
Successful program implementations.
Care plan coding and billing generating over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Every number on this page traces to the CoachCare Value Analysis workbook or cited public data. The key assumptions: