A scalable, profitable remote care service line for Rosemark Women Care Specialists: remote monitoring and chronic care management for the Medicare women your clinicians already see, billed under Rosemark’s own NPIs and run by a CoachCare care team inside Greenway
Medicare is changing what it pays for. Four shifts are under way at once, and each one lands in the same place: the months between a patient’s visits. For a women’s practice whose Medicare patients carry high blood pressure, high cholesterol, osteoporosis and diabetes, those months decide how the year goes.
Since 1994 Rosemark Women Care Specialists has cared for the women of Idaho Falls through every stage of life. Fourteen clinicians practice under one roof on Potomac Way: six physicians, among them a urogynecologist, two certified nurse-midwives, three nurse practitioners and three physician assistants. Bone density, ultrasound, lab work and bladder testing are done in the building. The practice runs its own clinical research program, and local readers have voted it Idaho Falls’ best OB/GYN clinic nine times.
An older panel of women in which high blood pressure and high cholesterol are the norm, and osteoporosis, diabetes, depression and kidney disease are common.
High blood pressure is the most common condition among Rosemark’s Medicare patients. Home readings catch what one office reading misses and let the care team act month to month instead of visit to visit.
25% of Rosemark’s traditional-Medicare patients have osteoporosis, 25% diabetes and 20% chronic kidney disease. Most carry two or more chronic conditions, which is the patient chronic care management was written for.
About 24% of the panel carries a depression diagnosis and 25% anxiety. Rosemark already treats both; monthly care management adds a screening and a check-in between visits.
Each step below added clinicians, services or space. Click through the years. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of Rosemark touches a patient at one moment: a gynecology visit, a bone-density scan, a urogynecology appointment, a lab draw, a surgery. A remote care service line connects them, so a patient who leaves one visit is still being watched until the next one. Select any part of the practice to see what changes.
Rosemark’s physicians, nurse-midwives, nurse practitioners and physician assistants set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the Greenway system Rosemark already uses, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. Greenway already holds the diagnoses, vitals, labs and medications. Medicare patients with high blood pressure, diabetes, kidney disease or several chronic conditions are flagged using criteria Rosemark’s clinicians set, so the right women surface at a gynecology visit, a bone-density scan, a urogynecology appointment, or on an outreach list.
Example criteria. Rosemark’s clinicians set and own the flag logic for each condition.
Patients enter at a visit for high blood pressure, or through care management for several conditions at once. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 156/92 at a gynecology visit, the second high reading in a row. The clinician places the remote care order before the patient checks out.
A cellular cuff at home, a welcome call from her care manager, and how to take a reading that counts.
99453Home averages go to the treating clinician each month; the CCM call covers the other conditions.
99454 · 99457 · 99490Office visits ↻ care management ↻ physiologic monitoring.
Diabetes, high blood pressure and osteoporosis on one chart. Flagged at a visit or from the outreach list.
Consent recorded, a care plan built across every condition, and the clinician signs it in the chart.
99490A cellular glucometer and cuff ship to the home. Readings start the day they arrive.
99453 · 99445Office visits ↻ care management ↻ physiologic monitoring.
The clinician orders from the chart, or a CoachCare enrollment specialist working in the office enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. Call times and the escalation contacts are set with Rosemark before launch.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in Greenway 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 Rosemark designates, in Greenway, 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 office. A critical reading on its own goes to the office. This cannot be configured away.
At month end, three things come out of the program: clean claims in Greenway, an operational report for the practice’s leadership, and a clinical outcomes report for the clinicians.
The integration creates the 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 a Rosemark remote care service line: remote monitoring and chronic care management across the Medicare panel, priced at Idaho’s CY2026 Medicare rates with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
One or two visits a year leave more than 360 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.
High blood pressure is the most common condition among Rosemark’s Medicare patients 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 office reading.
Cardiac Solutions, a physician-owned cardiology practice in Arizona, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
Medicare’s MIPS program scores clinicians on quality measures, and Rosemark can report as a group. Several of the measures that fit a women’s practice depend on work this program does every month. Select a measure to see how.
Monitoring the panel every day tells the practice 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.
Rosemark’s surgeons operate on women who carry high blood pressure or diabetes into the operating room. Patients already on monitoring keep their readings going through recovery, so a problem shows up before the follow-up visit, not at it.
Home averages in the chart give the surgeon a true blood-pressure baseline.
Gynecologic, pelvic-floor or bladder surgery at the hospital.
Readings continue at home; pain medicines and missed doses show up in the data.
Monthly RPM and CCM pick up where they left off.
Home readings before surgery and through recovery, with a call when pressure stays high after discharge.
Glucose while eating and medications change after surgery, with a check-in when readings run high.
Bladder symptoms and recovery questions on the monthly call, and a urogynecology visit when they change.
The care plan carries every condition through recovery, so nothing waits for the post-operative visit.
Every code the service line bills, at CY2026 Medicare rates for Idaho. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Idaho locality 00 (Noridian, MAC 02202). Only one device code (99454 or 99445) and one first-tier management code (99457 or 99470) bill per patient per month. About 38% of Bonneville County’s Medicare beneficiaries are in Medicare Advantage. Those plans must pay at no less than 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.
Many of Rosemark’s Medicare patients also see a primary care physician. Rosemark can start with remote monitoring alone, or run both programs through CoachCare for the women it manages. Either way the program is net-positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $265,356 | $294,170 | $559,526 |
| CoachCare cost (program and Greenway integration fees) | $155,324 | $165,382 | $320,706 |
| Net to Rosemark after fees | $110,031 | $128,788 | $238,819 |
| Margin to Rosemark | 41.5% | 43.8% | 42.7% |
| By program: remote monitoring $282,008 · chronic care management $277,518 in net reimbursement. Month 1 runs −$2,842 while implementation and the Greenway setup post against a census still ramping; net-positive from month 2. Medicare fee-for-service reimbursement only. | |||
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. Rosemark’s own Medicare chart count is the first thing to plug in.
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.
Rosemark’s physicians, nurse-midwives, nurse practitioners, physician assistants and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. Rosemark would otherwise need to recruit and keep them.
The enrollment specialist working in Rosemark’s building and device logistics are CoachCare’s expense.
Direct integration with the Greenway system Rosemark already runs, built on Greenway’s own workflows for Intergy and Prime Suite. Clinicians never leave the chart, and evidence of care, vitals and care plans are attached to it every month. Integration setup is a one-time $2,500, with no monthly or per-patient fee, confirmed in contracting.
Greenway Intergy overview Greenway Prime Suite overviewThe staff, protocols and Greenway workflow built for remote monitoring and chronic care management can take on the next programs Rosemark’s Medicare patients qualify for, without a second hiring plan.
About one in four of Rosemark’s Medicare patients carries depression or anxiety. Monthly behavioral health integration fits the same care-manager calls and the same chart.
For the women who use Rosemark as their primary care home, APCM pays a monthly amount per patient in place of CCM, tiered by complexity. Whether and when to move patients from CCM to APCM is a program decision to make together.
For a woman whose care at Rosemark centers on one serious condition, principal care management bills the same monthly calls against that condition alone.
Six reasons this partnership fits Rosemark specifically, not remote care in general.
Rosemark already offers primary care, bone health, mental-health care and dietitians for women of all ages. Remote monitoring and monthly care management put that care on a schedule between visits, for the Medicare women who qualify.
Built on Greenway’s own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible to every clinician in the building.
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, and fees are per active patient per month, with no capital outlay.
Rosemark’s physicians and advanced practice clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under Rosemark’s own billing entity and NPIs.
A physician-owned practice since 1994 adds Medicare revenue that does not depend on another procedure or another visit, at a margin of 42.7% over 24 months, without adding staff.
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 zero readmissions among 450 advanced heart-failure patients at Iowa Heart (case study).
The ask: a working session to confirm Rosemark’s Medicare chart count by payer, map which of those patients Rosemark manages for blood pressure, diabetes and mood and which see an outside primary care physician, scope the Greenway integration, and choose the starting deployment before the first enrollment.
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