Project Case Study

Your Medical Group is Losing Millions

•10 min read
Healthcare
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Business
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Your Medical Group is Losing Millions

Context: I sourced a deal and put together an analysis for a small medical group. They were impressed and I partnered with them to develop and launch the software. While I can't speak to specifics, all staff are still using and paying for it currently. They are seeking ways to expand the program and I am consulting with them on how to build the team to do it. Below you'll find a replica deck and a brief for healthcare administrators to accommodate the presentation. Contact information or proof of revenue is available upon request.




Executive takeaway: Independent medical practices and groups are missing out on significant recurring revenue opportunities while struggling with margin pressure. They can add a durable, recurring revenue stream and improve chronic care outcomes by standing up Medicare Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) if the program is built rules-first and audit-ready, run with tight operational discipline, and amplified by software. This platform codifies and operationalizes the regulations, automates documentation and billing readiness, and drives patient activation so revenue is captured compliantly every month. [CMS][HHS]

Why act now?

  1. Margin pressure is structural. In the last decade, the share of physicians working in private practice fell from 60.1% to 46.7% - a clear signal of financial and administrative strain on independents. New, predictable revenue is no longer optional. [AMA]
  2. CCM/RPM pay monthly. CCM and RPM codes reimburse every month per patient when criteria are met, turning work between medical visits, such as care coordination, into recurring revenue. (CMS MLN booklets and telehealth/RPM guidance specify eligibility, minutes, and day-count rules.) [CMS][CMS][HHS]
  3. Programs improve outcomes and total cost. Federal evaluations associate CCM with lower hospital/ED utilization and ~$74 per beneficiary per month (PBPM) savings by 18 months; scaled remote programs report ~$2,200 per member per year (PMPY) savings with strong disease-control rates. [MGMA/CMS eval][Ochsner][Validation Institute]
  4. Compliance scrutiny is rising. OIG flagged RPM as a 2025 focus (>$500M Medicare spend in 2024); risks include no prior relationship, multiple devices, and thin treatment-management documentation. A compliance-by-design operating model is now table stakes. [OIG 2025][OIG 2024]

CCM/RPM is both a care and margin imperative. However, managing without proper tooling creates an administrative and compliance nightmare. The winning play is to implement them with software-enforced controls and repeatable operations, and not ad-hoc phone calls, spreadsheets, timers, and haphazardly connected tools.

What “good” looks like?

Governing idea: Treat CCM/RPM as a new service line with three dimensions: Revenue, Outcomes, Compliance. Then, operationalize it with software and LLM-assisted automations.

1. Revenue: recurring, defendable cash flows

  • Monthly reimbursements accrue when requirements are met:
    • CCM: time thresholds and care-plan management (e.g., 99490, 99439, 99487/99489, 99491).
    • RPM: device setup/supply and treatment-management minutes; device codes require ≥16 days of data in 30 days; only one practitioner bills per patient per 30-day period. [CMS][HHS][CMS]
  • In practice, 100 CCM patients can approach a six-figure annual run-rate; paired CCM+RPM cohorts expand the pool and ARPM. (Exact dollars vary by locality/complexity; model with conservative ranges.) Published evaluations and case examples show clinics can achieve material monthly revenue within a quarter once activation is solved. [MGMA/CMS eval]

2. Outcomes: measurable clinical improvement

  • CCM reduces avoidable utilization. A CMS-summarized literature base associates CCM with lower hospitalizations and ED use and ~$74 PBPM savings by month 18 (less inpatient/post-acute spend). [MGMA/CMS eval]
  • RPM drives disease control. At Ochsner, a scaled program achieved 79% BP control at six months and 81% A1c control, with ~$2,200 PMPY savings - evidence that remote management can materially bend outcomes and cost curves. [AMA][Ochsner]
  • Adding templates and protocols into custom care plan templates, RPM alerts, and integrated training protocols can empower clinical and non-clinical staff to collect highly relevant data that would otherwise go unnoticed and unaddressed.

3. Compliance Engine: audit-ready by design

  • We encode the RPM 16-day rule, one-practitioner limit, medical necessity, and documentation elements into workflows with hard stops, alerts, and immutable logs - aligned to OIG's current focus areas. [HHS][OIG 2025][OIG 2024]
  • We add in daily and weekly prompts for patients to review their health and take action, and a clinician callback if they don't.
  • We keep a running log of daily patient interactions with automatically timestamped interactions.
  • Monthly, the system produces claim-ready packets (time logs, device-day logs, interactions, care-plan updates) and flags potential denials pre-submission. This turns compliance from a risk into an advantage.

Evidence and Data

Market reality: independents need new, predictable margin

Trend: AMA’s decade review shows a 13-point drop in private-practice employment share (60.1% → 46.7% between 2012–2022), reflecting payment pressure and rising admin costs. [AMA]
So what: CCM/RPM monetizes between-visit work you already do, as a recurring line, with measurable clinical upside.

Policy and rules: what Medicare actually pays for

  • CCM (MLN909188): Non-face-to-face care for ≥2 chronic conditions; requires a comprehensive care plan, documented minutes, and continuity; code families cover basic through complex. [CMS]
  • RPM (MLN901705 / HHS Telehealth): Device data collection ≥16 of 30 days (device codes), interactive treatment-management minutes (99457/99458), established patient relationship, and one practitioner per month. Treatment-management codes are not subject to the 16-day count. [HHS][CMS]

Outcomes and savings: not just theory

  • CCM: Evaluations attribute net per-beneficiary savings to CCM, e.g., ~$74 PBPM at 18 months, while physician payments increased - evidence Medicare is "buying" less acute spend via care management. [MGMA/CMS eval]
  • RPM/remote programs: Ochsner’s program demonstrates clinical control and financial ROI under value-based arrangements; repeated remote models show utilization reduction when adherence is high. [AMA][Ochsner]

Adoption momentum: your clinicians are ready

Physician sentiment toward digital health is mainstream; the AMA's 2022 Digital Health Study documents growing adoption and perceived value of remote monitoring and related tools - reducing change-management friction. [AMA][AMA]

Integrity climate: design for audits from day 0

OIG’s 2024/2025 work highlights RPM spend (>$500M in 2024) and patterns to monitor: no prior relationship, multiple devices billed, and insufficient treatment-management documentation. Programs that prove necessity and interactions will withstand scrutiny. [OIG 2025][OIG 2024]

How to launch (and scale) like a top-quartile program

1. Define the first 300 patients (where outcomes and ROI are largest).
Segment by impact and engagement probability:

  • Tier 1: Uncontrolled HTN, CHF, COPD, insulin-treated DM.
  • Tier 2: Multi-morbidity with polypharmacy.
  • Tier 3: Stable chronic conditions needing adherence nudges.
    This sequencing maximizes early clinical wins and cash flow.

2. Choose the operating model.

  • Partnered (fastest time-to-value): Offload operations (outreach, device logistics, monthly documentation, claim packs) to our team + software; your clinicians approve enrollments and handle escalations.
  • Hybrid / in-house (for larger groups): Use your staff, our software, and our playbooks. You retain more margin; we keep you audit-ready.

3. Enforce the rules in software (not in binders).

  • RPM day-count tracker with risk alerts (Day 10/13/15) and a claim block if <16 days (for device codes).
  • Interactive-minutes timers and structured notes for 99457/99458.
  • One-practitioner lock and device/NPI dedupe checks.
  • CCM consent capture and care-plan completeness checks aligned to MLN. [CMS][HHS]

4. Industrialize patient engagement (activation drives revenue).

  • Live onboarding call, first reading within 48 hours, message nudges on Days 3/6/10/13, clinician callback after 3 no-read days.
  • Dashboard on activation %, 16-day runway, minutes bank, and escalation queues. (These leading indicators predict both outcomes and revenue.)

5. Run it as a business line: SLA and KPI-driven.

  • SLAs: outreach ≤3 business days; ship device ≤48h; activation ≥75% in 7 days; 16-day compliance ≥90%; denial rate ≤5%.
  • KPI tree: eligible→enrolled conversion; adherence; minutes attainment; first-pass acceptance; appeals win-rate.

6. Start with a 90-day pilot; scale in tranches.

  • Weeks 0–2: EHR connection and registry; consents; care-plan templates.
  • Weeks 3–4: First 50 live to prove activation mechanics.
  • Month 2: 150–200 live. Month 3: 300+ if KPIs green.
  • Expand in 300-patient tranches; maintain ratios with automation.

What you should expect

Conservative, locality-agnostic illustration per 100 enrolled patients (annualized):

  • Mid case: Enrollment 70; compliance 85% → ~$125k gross; program costs (care team, devices/logistics, platform) ~$55k; ~$70k net; 5-month payback.
  • Best case: Enrollment 90; compliance 95% → ~$175k gross; ~$110k net; 3-month payback.
  • Worst case: Enrollment 50; compliance 70% → ~$80k gross; ~$35k net; 8-month payback.

Your actuals vary by Medicare locality rates, complexity mix, and payer mix. These ranges align directionally with published CCM savings and with remote program ROI (e.g., ~$2,200 PMPY savings) under value-based contracts. [MGMA/CMS eval][Validation Institute]

Clinical signal you can publish internally within 90 days:

  • ↑ % patients at BP/A1c goal (Tier-1 cohorts)
  • ↓ urgent call volume and avoidable ED checks
  • ↑ documented med reconciliation and adherence touchpoints
  • ↑ HEDIS-like process measures (e.g., monitoring frequency)

What to ask any vendor (including us)

  • Rules enforcement: How do you enforce 16-day RPM counts, treatment-management minutes, the one-practitioner rule, medical-necessity prompts, and care-plan completeness before claims go out? (Show alignment to MLN/HHS Telehealth.) [HHS][CMS]
  • Audit readiness: Do you generate a monthly packet (time logs, device-day logs, interactions, care-plan updates) with immutable audit trails?
  • Activation at scale: Share activation/adherence benchmarks (Day-2 first-reading rate, 7-day activation %, 16-day compliance).
  • Denial prevention: Demonstrate claim scrubs/blocks for common RPM/CCM denial reasons and your appeals win-rate.
  • Governance: Provide SLA/KPI dashboards and a cadence for monthly steering with CMO/CFO/COO.
  • Tailoring Service to Specialized Needs: How do they codify practice or provider specific knowledge, protocols, and processes?

Bottom line

  • Decision: Launch CCM/RPM as a software-enforced service line now.
  • Why: It adds recurring margin, improves outcomes, and when done right reduces audit risk.
  • How: Start with the first 300 patients, enforce rules in software, manage to SLAs/KPIs, and scale in 300-patient tranches.
  • With us: You get an operating system purpose-built for Medicare rules, activation at scale, and audit-ready documentation so your clinicians can focus on care while the program quietly spins off compliant, predictable revenue.

References

  1. American Medical Association (AMA). Policy Research Perspectives: Changes in Physician Practice Arrangements, 2012–2022.
  2. Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Services (MLN909188), June 2025.
  3. U.S. Department of Health and Human Services (HHS). Billing for Remote Patient Monitoring (RPM), updated Jan 17, 2025.
  4. CMS. Telehealth & Remote Patient Monitoring (MLN901705), April 2025.
  5. Medical Group Management Association (MGMA) summary of CMS CCM evaluation: savings and utilization impacts.
  6. AMA. Digital Health Study 2022: Physician adoption and attitudes.
  7. AMA. Ochsner Health sees big return on investment in remote care, Aug 12, 2024.
  8. Ochsner / Validation Institute. >$2,200 per member per year savings from Ochsner Digital Medicine, June 26, 2023.
  9. HHS Office of Inspector General (OIG). Billing for Remote Patient Monitoring in Medicare, Aug 28, 2025.
  10. HHS OIG. Additional Oversight of Remote Patient Monitoring in Medicare Is Needed, Sept 24, 2024.
  11. AMA. Digital Health Research PDF (detail deck), 2022.