OVP Health Care ranks in the top national quartile for substance use disorder treatment initiation and engagement — sustained contact with the patients most health centers lose track of. On every chronic-disease measure, the same organization ranks in the bottom quartile. Both depend on what happens between visits. One has the infrastructure and the other does not, and since January 1, 2026 the work of building it is separately billable Medicare revenue.
The headline counts 151 unique patients in active remote care at Month 24. The enrollment chart and the Scenario Explorer show 231 active program enrollments (services): CCM and APCM cannot be billed for the same patient in the same month, so the 61 CCM and 54 APCM enrollments are 115 distinct care-management patients. Most of the 116 RPM enrollments sit inside those cohorts as a second program on the same patient, and the balance are monitoring-only — together, 151 unique patients. Program enrollments are never labeled “patients.”
Health centers report clinical quality to HRSA every year and are ranked against every other health center in the country. On substance use disorder treatment, OVP Health Care ranks in the best-performing quartile nationally — while carrying an SUD caseload that is 41.3% of the entire patient panel.
Top national quartile. The share of patients who start treatment after diagnosis — the step most programs lose people at.
Top national quartile. The share who stay in treatment. This is a between-visit measure, and OVP already wins it.
Up from 578 two years earlier. Mental health rose from 222 to 1,077 across the same period.
These are the measures that move when someone checks in between appointments, and they are the ones a quarterly office visit cannot reach. Two of them have a device attached.
27.2% of the panel, up from 246 the year before as diagnosis capture improved. Across the Medicare panels specifically, hypertension prevalence runs 72–75%.
17.1% of the panel. Diabetes prevalence in the Medicare panels runs 29–54%, and chronic kidney disease 25–49%.
Also bottom quartile, across 1,530 patients. The same monthly contact that carries blood pressure carries this one.
G0511 — the single bundled code that paid health centers one flat amount for roughly twenty distinct care-management services — is gone. Since January 1, 2026, federally qualified health centers and look-alikes bill the individual CCM, RPM and APCM codes at national non-facility Physician Fee Schedule rates, each separately payable in addition to the PPS encounter rate.
PPS still pays for the visit. Care management and remote monitoring pay on top of it rather than folding into it, so a remote-care program does not cannibalize the encounter.
These codes pay the national amount wherever the clinic sits. Every one of OVP's Medicare localities pays below national, so the correct rail is worth 5.6% to 7.6% more than local physician-fee-schedule rates across the code set.
Each program now needs its own time capture and its own documentation. That is the operational cost of the change, and it is the part CoachCare absorbs.
Modeled across the 510 Medicare and dual-eligible patients in OVP's panel — the population where these codes pay at Medicare rates. CoachCare supplies the devices, the enrollment staff, the monitoring hours and the documentation. The health center supplies the panel and the clinical decisions.
Remote physiologic monitoring. Blood-pressure cuffs and glucose meters that transmit on their own — 99453 setup, 99454 device supply, 99457 and 99458 treatment management, plus the CY2026 short-window codes 99445 and 99470. Reaches 65% of the in-scope panel and stacks with either care-management rail.
Chronic care management. Monthly non-face-to-face management for patients with two or more chronic conditions, which at 72–75% hypertension prevalence is most of this panel. 99490 and 99439.
Advanced primary care management. No minute thresholds and no time sheets — a monthly per-patient payment tiered by complexity. G0556, G0557 and G0558, where the top tier pays most for qualified Medicare beneficiaries who also carry Medicaid. 148 of the 510 are dual-eligible.
Seven sites across five counties and three states, including a mobile unit in HRSA-approved scope since March 2024. Enrollment requires no one to travel: the on-site specialist works the highest-volume site and telephonic outreach covers the rest.
CoachCare builds on Epic's own workflows, so the care team enrolls and monitors patients without learning a second system. Readings, documentation and claims all land in the chart the clinicians already work in.
Enrollment flags and trigger ordering sit inside the clinical workflow. The CoachCare team enrolls qualified Medicare patients on the health center's behalf, and enrollment status is visible in Epic in real time.
Bi-directional at intake, so the care team starts with the same problem list, medications and history the clinic has.
Blood pressure, weight and glucose readings post as structured data on the patient record rather than as attachments nobody opens.
An integrated care summary lands in the record. Under the CY2026 individual-code rules each program needs its own time capture and its own documentation, and this is what substantiates the billed time when a payer asks.
Claims are created by the CoachCare billing engine. CoachCare is the only care-management application integrated with Epic that generates claims automatically, which removes the manual per-patient, per-month claim step entirely.
The economics prove the service line pays. This is what keeps it safe, and with one physician on staff it is the part the care team should read first.
The care team retakes it and screens for symptoms before anything escalates. A single high number is a measurement; a confirmed one is a finding.
A patient who feels fine with a critical reading still escalates. Feeling well is not a reason to wait.
Three readings at least an hour apart for blood pressure or glucose, or three within seven days for heart rate. Not a judgment call, and not a different threshold depending on who is working.
Voicemail and a callback attempt are logged, and a critical value or confirmed trend escalates anyway. Silence never closes a case.
Emergencies go to 911. Non-critical findings go to a named member of the practice team. Stable and resolved goes into the record as an FYI, so the clinic is not paged for readings that resolved themselves.
Vital, findings, method of contact, who was reached, outcome, and follow-up. That record is also what substantiates the billed time.
A 24-month forecast across the 510-patient Medicare and dual-eligible population, 12 referring clinicians, one CoachCare-funded on-site enrollment specialist, telephonic enrollment, and CY2026 national non-facility PFS rates. Medicaid revenue, 340B pharmacy effects, transitional care management and the value of avoided admissions are not in these numbers.
| Program | Year 1 | Year 2 | 24‑Month |
|---|---|---|---|
| RPM net reimbursement | $112,303 | $134,459 | $246,762 |
| CCM net reimbursement | $72,240 | $81,335 | $153,575 |
| APCM net reimbursement | $36,368 | $38,220 | $74,588 |
| Total net reimbursement | $220,911 | $254,014 | $474,925 |
| CoachCare fees (incl. one-time) | $130,985 | $141,917 | $272,902 |
| Net to the health center | $89,926 | $112,097 | $202,023 |
| Margin to the health center | 40.71% | 44.13% | 42.54% |
Roughly $253,000 of avoided acute cost over 24 months. That value accrues to the health system and to payers rather than to OVP, so it is excluded from every revenue figure above.
Blood pressure, weight and glucose readings arriving between visits, where the two failing quality measures are decided.
Coded, documented and submitted with the time capture the CY2026 individual-code rules require.
About 1.56 full-time equivalents of care-management capacity, added without the health center hiring anyone.
The forecast above covers 510 Medicare and dual-eligible patients. OVP serves 2,510 Medicaid patients — five times as many. Everything the service line builds for Medicare is the same equipment, the same enrollment staff and the same escalation engine. What differs is whether a given state pays for it, and the three states OVP operates in answer that three different ways.
Ohio rule names remote patient monitoring as a service a health center may claim as a non-PPS service, and states that providing one on the same date as a PPS service does not preclude payment for either. That is incremental revenue, not a repackaged encounter. Ohio also pays APCM. Four of OVP's seven sites are in Ohio — Wheelersburg, Proctorville, Gallipolis and the mobile unit. Two conditions apply: a second Ohio provider number is required to bill non-PPS services, and no wraparound applies to them.
Kentucky covers remote monitoring and chronic care management under a dedicated regulation. But because those services count as a visit, they generate the encounter rate through wrap payment rather than an additional line. Worth building for the clinical result and the quality measures; not worth modeling as new revenue.
The state fee schedule lists the remote monitoring and chronic care management codes and marks them not covered. Transitional care management is covered and pays well, and it is the one care-management line available in West Virginia today.
Pull the exact Medicare and dual-eligible count from the practice management system, identify which Epic instance OVP runs on so the interface request goes into the right queue, and agree which site starts. The 601 20th Street Huntington clinic runs the longest hours of any site and entered scope most recently.
Enrollment flags and trigger orders built into the existing workflow, discrete vitals mapped to the chart, escalation routing set to the practice's own contacts, documentation templates mapped to the CY2026 individual-code requirements, devices staged, and the on-site enrollment specialist placed.
Enrollment begins in month 1 — there is no dormant onboarding period. The mobile unit and the telephonic pathway extend reach beyond the flagship site from the start.
APCM reaches its ceiling in month 2, CCM in month 4 and RPM in month 5. From there the conversation turns to Ohio Medicaid and to the quality measures the program was built to move.
Over 400 managed conditions.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than five million claims.
Over 100 million vitals recorded and more than 4 million care actions enabled.