A scalable, profitable remote care service line for Brookhaven Heart and MD365: remote monitoring and principal care management for the cardiology panel, remote monitoring and chronic care management for the primary care panel, billed under Brookhaven Heart’s own NPIs and run by a CoachCare care team inside eClinicalWorks
Brookhaven Heart’s cardiologists and MD365’s primary care clinicians see the same Long Island patients at different moments. Four changes arrived together in 2026, and each one pays for, or measures, what happens between those visits: the blood pressure that drifts after a dose change, the weight that climbs in week three, the patient sent home from the hospital on a Friday.
Brookhaven Heart is an independent, physician-owned cardiology group founded in Patchogue in 2006, with six cardiologists and a nurse practitioner covering interventional, peripheral vascular, imaging and heart-failure care from offices in Patchogue and New Hyde Park. It also runs its own primary care network, MD365, with eight physicians and nine nurse practitioners and physician assistants across ten Long Island offices. Both bill under one Medicare number and share one eClinicalWorks system, and since January 2026 both sit inside a Medicare Shared Savings Program ACO. Together they care for about 6,100 Medicare patients.
Two panels on one chart. The cardiology panel is older and higher-risk, average age 75, with diabetes in nearly half; the MD365 panel is the longitudinal primary care relationship, average age 71, where hypertension is just as common.
At least 75% of the cardiology panel’s traditional-Medicare patients have hypertension, and 44% have ischemic heart disease. Home readings give the cardiologist a real average to titrate against instead of one office reading every few months.
45% of the cardiology panel has diabetes and 28% chronic kidney disease. Blood pressure, sugar and kidney function move together, which is why MD365’s chronic care management and cardiology’s monitoring belong in one chart.
18% of the cardiology panel carries a heart-failure diagnosis and 24% atrial fibrillation. Weight and blood pressure change days before symptoms do, and a scale at home catches the change while a diuretic adjustment can still keep the patient home.
Each step below added physicians, sites or a way of paying for care. Click through the years. The next step builds out the part they all depend on: daily readings and a care team between visits, at the scale of both panels.
Each part of the practice touches a patient at one moment: a primary care visit at MD365, a cardiology follow-up, an echo, a procedure, a hospital stay. A remote care service line connects them, so a patient who leaves one encounter is still being watched until the next one. Select any part of the practice to see what changes.
Brookhaven Heart’s cardiologists and MD365’s clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Both brands already share one eClinicalWorks system, so one integration carries the work from the first flag on a patient’s chart to the claim at month end, at every office.
The program starts with the panel, not a referral pad. eClinicalWorks already holds the diagnoses, ejection fractions, vitals, labs and medications for both panels. Patients are flagged using criteria the practice sets: cardiology patients with heart failure, uncontrolled hypertension, atrial fibrillation or a recent admission go to principal care management; MD365 patients with two or more chronic conditions go to chronic care management. Each patient gets one care-management program, owned by the clinician who manages the condition.
Example criteria. Brookhaven Heart’s cardiologists and MD365’s physicians set and own the flag logic for each condition.
Patients enter at an MD365 or cardiology visit, after a test or procedure, or after a hospital stay. Each way leads into the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 158/92 on two agents, A1c 8.4. The MD365 clinician places the remote care order, or the enrollment specialist enrolls the patient before checkout.
Cellular cuff at home, a welcome call by phone, and how to take a reading that counts.
99453Home averages drive medication changes; the chronic care call keeps diabetes, kidney and blood pressure goals on one plan.
99454 · 99457 · 99490Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Scale and cuff ordered to the home.
Contact within two business days, medication reconciliation, a cardiology visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99426Office 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. The routine is set to fit the patient’s day.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in eClinicalWorks to the first billable day of service. Enrollment status is visible in the chart the whole way through, at every cardiology and MD365 office.
Readings that settle are logged in the chart and visible to the patient’s clinician without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the cardiologist or the MD365 clinician who owns that patient’s plan, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath, fainting 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 eClinicalWorks, an operational report for the practice’s leadership, and a clinical outcomes report for the physicians in both arms.
CoachCare is the only care-management application integrated with eClinicalWorks that creates 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 Brookhaven Heart remote care service line: remote monitoring and principal care management across the cardiology panel, remote monitoring and chronic care management across the MD365 panel, priced at CY2026 Medicare rates for the NYC Suburbs and Long Island locality with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
Two cardiology follow-ups a year leave 363 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.
The two outcomes a cardiology group cares about most, blood pressure and readmissions, have both been published from CoachCare programs at physician-owned cardiology practices.
Cardiac Solutions, a physician-owned cardiology practice with three West Phoenix offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
Since January 2026 Brookhaven Heart has been part of a Medicare Shared Savings Program ACO on the Enhanced track, and the ACO’s quality score sets how much of any savings it keeps. Several of the measures depend on work this program does every month. Select a measure to see how.
Monitoring both panels 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.
All four hospitals where Brookhaven Heart physicians hold privileges have been mandatory TEAM participants since January 2026, accountable for Medicare spending through 30 days after a coronary bypass discharge, and two of the four paid a heart-failure readmission penalty in FY2026. The cardiologists follow these patients home, and remote monitoring with principal care management carries them past day 30.
Flagged in eClinicalWorks for post-discharge monitoring.
A call within two business days and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly RPM with PCM or CCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, and guideline therapy steps scheduled while the patient is watched.
Blood pressure and heart rate while new medications settle, and a check that cardiac rehab has started.
Weight, blood pressure and symptoms through the 30 days the hospital’s bypass episode runs, with a call when something changes.
Rate and blood pressure after a cardioversion or a new rate-control agent.
Every code the service line can bill, at CY2026 Medicare rates for the NYC Suburbs and Long Island locality. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, New York locality 02, NYC Suburbs/Long Island (National Government Services, MAC 13202). Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (PCM or CCM) bill per patient per month. About 30% of Suffolk 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.
The service line runs in two arms on one billing number: cardiology and MD365 primary care. Each is net-positive on its own, and together they share one implementation and one eClinicalWorks integration. Select an arm to redraw the charts.
| Whole practice | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $2,005,447 | $3,743,310 | $5,748,757 |
| CoachCare cost (program and eClinicalWorks fees) | $1,160,729 | $2,143,227 | $3,303,956 |
| Net to Brookhaven Heart after fees | $844,718 | $1,600,083 | $2,444,801 |
| Margin to Brookhaven Heart | 42.1% | 42.7% | 42.5% |
| By arm: cardiology $2,637,728 (net $1,084,446) · MD365 primary care $3,111,029 (net $1,360,355) in net reimbursement. Month 1 runs −$1,416 while implementation and the eClinicalWorks setup post against a census still ramping; net-positive from month 2. Fee-for-service reimbursement only; shared savings are not counted. | |||
Change the assumptions and the 24-month forecast recalculates. Start from an arm or move the sliders yourself. The practice’s own Medicare chart count for each panel is the first thing to plug in: three of the four programs fill their eligible share inside the first year, so panel size moves this forecast almost one-for-one.
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 across both arms.
Brookhaven Heart’s cardiologists and MD365’s physicians, nurse practitioners and physician assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months across both arms, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. The practice would otherwise need to recruit and keep them.
Two CoachCare enrollment specialists, one for the cardiology offices and one across MD365, plus device logistics, are CoachCare’s expense.
Direct integration with the eClinicalWorks system Brookhaven Heart and MD365 already share, using its built-in workflows. Clinicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
eClinicalWorks integration overviewThe staff, protocols and eClinicalWorks workflow built for remote monitoring and care management can take on the next programs the practice’s patients qualify for, without a second hiring plan.
Brookhaven Heart’s cardiologists see their patients through hospital stays at four hospitals, and claims show no transitional care management at meaningful scale. The same care team can make the two-business-day call after each cardiac discharge, so the follow-up visit the practice already schedules can bill 99495 or 99496 ($254.35 or $344.57 at the local rate). It is left out of the forecast totals.
Patients scheduled for a catheterization, a stent or a peripheral procedure can go on blood pressure, heart rate and weight before the procedure and stay on them through recovery, with the same care team and the same chart.
MD365 patients whose blood pressure, swelling or rhythm points to the heart reach a Brookhaven Heart cardiologist with their home readings already in the chart, and cardiology patients with no primary care home are offered one at MD365. One chart and one care team keep both directions of the referral inside the practice.
Six reasons this partnership fits Brookhaven Heart specifically, not remote care in general.
The practice already bills remote monitoring and chronic care management for hundreds of patients, runs a heart-failure clinic, checks pacemakers and defibrillators remotely, and has MD365’s Connected Care. CoachCare scales that work to both panels, adds principal care management and a cardiology protocol, and staffs it, without the practice hiring a care team.
Built on eClinicalWorks’ own workflows. Cardiology and MD365 already share one system, so readings, documentation and claims live in the same chart, and enrollment status is visible at every office.
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.
Brookhaven Heart’s cardiologists and MD365’s clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under Brookhaven Heart’s own billing entity and NPIs.
A consented panel, documented monthly care management, daily physiologic data and a working post-discharge loop are what the ACO’s quality and cost results and the hospitals’ TEAM episodes both depend on. The service line produces all four under fee-for-service.
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 both panels’ Medicare chart counts by payer, map today’s remote care program and which patients move first, agree on the cardiology flag criteria, and scope the eClinicalWorks integration before the first patient enrolls.
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