A scalable, profitable remote care service line for HealthLinc: remote monitoring, chronic care management and advanced primary care management for the Medicare patients your health center already serves, billed under HealthLinc’s own NPIs on top of the PPS encounter and run by a CoachCare care team inside Greenway Intergy
Medicare is changing what it pays health centers for. Four shifts are under way at once, and each one lands in the same place: the weeks between a patient’s visits. For a health center whose Medicare patients carry hypertension, diabetes and depression together, those weeks decide how the year goes.
HealthLinc started in 1996 as one health center in a Valparaiso neighborhood house and became a federally qualified health center in 2006. Today it runs 18 clinics from East Chicago to rural Starke and Newton counties, four of them in Elkhart since its merger with Heart City Health in October 2026. Together the two served more than 73,000 patients in 2025, 7,453 of them on Medicare. Most sites put medical, behavioral health and clinical pharmacy care in one building, and HRSA ranks HealthLinc a national quality leader in heart health and in behavioral health.
A Medicare panel that is growing every year, in which hypertension and diabetes are the norm, more than a third of patients also qualify for Medicaid, and the health center already scores in HRSA’s top quartile on the measures that remote care moves.
HRSA named HealthLinc a National Quality Leader in heart health, and blood-pressure control sits in the top quartile of health centers. With 13,573 hypertensive patients across both health centers, the next points come from home readings and medication changes between visits, and the program puts the four Elkhart sites on the same routine from the start.
Poor A1c control is already lower than at three in four health centers. Across 7,539 patients with diabetes at both health centers, about 1,500 were still above 9% or untested in 2025, and most of them carry hypertension too. Home glucose and a monthly care-management call reach them between lab draws.
HealthLinc screens nearly nine in ten adult patients for depression and holds a National Quality Leader badge in behavioral health. Remission at twelve months is the measure that lags, and it is the one that depends on follow-up between visits.
Each step below added sites, services or patients. 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 HealthLinc touches a patient at one moment: a medical visit, a behavioral health appointment, a pharmacy pickup, a dental chair, a hospital discharge. 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 health center to see what changes.
HealthLinc’s physicians and advanced practice clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the Greenway Intergy system HealthLinc 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 HealthLinc reports to HRSA every year. Patients with uncontrolled hypertension, diabetes or several chronic conditions are flagged using criteria HealthLinc’s clinicians set, so the right patients surface at a visit, at an annual wellness visit, or on an outreach list.
Example criteria. HealthLinc’s clinicians set and own the flag logic for each condition.
Patients enter at a medical visit, at their annual wellness visit, or after a hospital stay. Either way they land in the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 162/96 on three agents and an A1c above 9. The clinician places the remote care order during the visit, or at the annual wellness visit.
Cellular cuff and glucometer at home, a welcome call, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the care-management call covers the other conditions.
99454 · 99457 · 99490 or G0557Office visits ↻ care management ↻ physiologic monitoring.
Flagged in Greenway when the discharge notice arrives. Devices ordered to the home.
Contact within two business days, medication reconciliation, a HealthLinc visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99490Office visits ↻ care management ↻ physiologic monitoring.
The clinician orders from the chart, or a CoachCare enrollment specialist working at a HealthLinc site 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 language plan for Spanish-speaking patients is set with HealthLinc 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, at every site.
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 each site 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 site. A critical reading on its own goes to the site. This cannot be configured away.
At month end, three things come out of the program: clean claims in Greenway, an operational report for HealthLinc’s leadership, and a clinical outcomes report that lines up with the measures HealthLinc reports to HRSA.
The integration creates the claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the health center. Sample below at the modeled month-12 census.
A 24-month forecast for a HealthLinc remote care service line: remote monitoring, chronic care management and advanced primary care management across the Medicare panel, priced at the CY2026 national rates health centers bill, on top of the PPS encounter, with every patient priced at the Medicare amount. Alongside it, what the program does for patients and for the people who run it.
Four visits a year leave 361 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.
Hypertension is the most common chronic condition at HealthLinc 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 practice with three offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
HealthLinc reports clinical quality to HRSA every year, and its clinicians now take part in an Enhanced-track Medicare Shared Savings Program ACO that is scored on an overlapping set. Most of these measures depend on work this program does every month. For patients assigned to the ACO, Medicare pays for the services on HealthLinc’s claims, these programs included, through the ACO’s monthly primary-care payment instead of claim by claim, and a CMS guardrail keeps that payment at or above the claims it replaces. For every other Medicare patient the codes pay claim by claim. Select a measure to see how.
Monitoring the panel every day tells the health center who needs to be seen now, which the schedule alone cannot. Patients surface from their home data before they come in sicker.
When a HealthLinc patient goes home from the hospital, the next 30 days decide whether they come back. Transitional care management pays for that month; remote monitoring and care management carry the patient past it.
Flagged in Greenway 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 CCM or APCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, a cardiology referral when the trend returns.
Oxygen saturation and symptoms after an exacerbation, with a quick visit before a return trip to the emergency department.
Glucose and BP while medications change after a stay, and a fluid check for patients with CKD.
Patients who carry hypertension or diabetes into a behavioral health admission stay on their readings and their monthly call until the follow-up visit.
Every code the service line can bill, at the CY2026 national Medicare rates health centers bill. Since January 1, 2026, a health center bills each of these on its own, in addition to the PPS encounter for the visit. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, national non-facility amounts: the rate a federally qualified health center bills for these codes at every site, in addition to the PPS encounter. Indiana Medicaid pays health centers per face-to-face visit, so the forecast counts Medicare only. Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program (CCM or APCM) bill for a patient in a given month. About 48% of Medicare beneficiaries across HealthLinc’s seven counties are in Medicare Advantage (56% in St. Joseph County). 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.
HealthLinc can hand CoachCare the remote monitoring and keep care management with its own team, or run all three programs through CoachCare. Either way the contribution margin is positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Unique patients, end of period | 1,015 | 1,546 | 1,546 |
| Contribution margin | $312,712 | $992,031 | $1,304,743 |
| Contribution margin runs −$3,938 in month 1 while the program ramps; positive from month 2. Medicare fee-for-service only, in addition to the PPS encounter; no shared-savings or grant dollars are in these figures. | |||
Over 24 months that is −$135,367 of contribution margin on remote monitoring and −$162,347 on the whole service line.
Two ways to run the same program, on the same Medicare panel, the same national rates and the same 24 months. Full Service is the forecast on this page: devices, software and the CoachCare care team. Self Service gives HealthLinc the same devices and software inside Intergy and leaves the care team, enrollment and the monthly minutes to HealthLinc’s own staff, the way its nurses run chronic care management today.
Self Service runs the same enrollment engine with two things an in-house team carries: enrollment at three-quarters of the pace, because nobody’s whole job is enrolling, and a quarter fewer billable remote-monitoring and chronic-care minutes, because time-based codes pay only when the minutes are logged every month. HealthLinc employs the clinical minutes.
| 24 months | Full Service | Self Service |
|---|---|---|
| Program enrollments by month 6 | 570 | 428 |
| Unique patients, month 24 | 1,546 | 1,316 |
| Contribution margin, Year 1 · Year 2 | $312,712 · $992,031 | $70,127 · $563,159 |
| Contribution margin, 24 months | $1,304,743 | $633,286 |
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. HealthLinc’s own Medicare chart count by payer 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.
HealthLinc’s physicians, nurse practitioners, nurses and medical assistants keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare, at a time when every health center is competing for the same nurses.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. HealthLinc would otherwise need to recruit and keep them.
The enrollment specialist working at HealthLinc sites and device logistics are CoachCare’s expense.
Direct integration with the Greenway Intergy system HealthLinc already runs, built on Greenway’s own 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.
Greenway Intergy integration overviewThe staff, protocols and Greenway workflow built for remote monitoring and care management can take on the next programs HealthLinc’s patients qualify for, without a second hiring plan.
HealthLinc holds a National Quality Leader badge in behavioral health. Monthly behavioral health integration fits the same care-manager calls and the same chart, and it is the program built for depression remission.
A call within two business days of every discharge and a visit inside two weeks, run on the same escalation engine and billed by HealthLinc.
Medicare now pays for community health workers’ time addressing the social needs that get in the way of treatment. The same care-plan record and monthly cadence carry it.
Six reasons this partnership fits HealthLinc specifically, not remote care in general.
HealthLinc already scores in HRSA’s top quartile on blood pressure and diabetes, and its own team already runs care management for many of its patients. Remote monitoring adds daily readings to that work, and CoachCare can take on as much or as little of the care management as HealthLinc wants.
Built on Greenway’s own Intergy workflows and supported alongside Greenway. Readings, documentation and claims live in the chart, and enrollment status is visible at every site.
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, with no capital outlay.
HealthLinc’s physicians and advanced practice clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under HealthLinc’s own billing entity and NPIs, separate from the PPS encounter.
Cellular devices that need no home internet and nothing to pair, for rural patients in Starke and Newton counties as much as for patients in East Chicago and South Bend. Enrollment, device instructions and outreach are scoped with HealthLinc for Spanish-speaking patients before the first patient enrolls.
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 with HealthLinc’s leadership to confirm the Medicare chart count by payer and ACO assignment across the merged health center, walk through how chronic care management and Food-as-Medicine monitoring run today, map the monitoring and billing requirements of the HRSA telehealth nutrition award, and scope the Intergy workflow for all 18 clinics with Greenway.
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