For ACOs & Value-Based Care Organizations
Care Management and Remote Monitoring for ACOs and Value-Based Care Organizations
Your benchmark is set across every attributed patient, but your member practices run care their own way. We give the whole network one between-visit program, and the fee-for-service codes it bills help pay for it.
HIPAA · SOC 2 Type II
No long-term contract
Live in about 30 days
Rising-risk cohortEnrolled before they become high-cost
Attributed population, network viewLive
Member practices liveOne protocol set14
Patients on RPMHypertension and HF1,280
BP control gaps trackedLast reading <140/90Daily
FFS revenue to practicesRPM, CCM, APCMMonthly
2,000+Providers on HealthArc
100,000+Patients monitored
45+States covered
9CMS programs, one platform
What’s Changing
The ACO Model Is Changing, and the Work Between Visits Isn’t
ACO REACH ends on December 31, 2026. CMS’s successor, the LEAD model, starts January 1, 2027 and runs through 2036, with fixed benchmarks and two risk tracks.
MSSP has 511 ACOs participating in 2026.
The models keep changing.
Whichever track you’re on, savings come from the same place: patients with chronic conditions who don’t end up in the ED, and quality measures that are closed during the year instead of chased in the fourth quarter.
In our experience the ACOs that do well on those numbers aren’t the ones with the best dashboards; they’re the ones where someone actually calls a patient with a blood pressure of 162 over 98 in the same week the reading comes in, and gets the medication changed before the next quarterly visit.
ACO REACH
Ends December 31, 2026
LEAD model
January 2027 to 2036
MSSP ACOs in 2026
511
Who funds the work
FFS care-management codes
Member practices vary
One practice has a care manager, another has none. Your results depend on the weakest site, and you don’t control its staffing.
Analytics don’t make calls
Most ACOs already know who their rising-risk patients are. The gap is someone contacting them every month.
Care management costs money up front
Shared savings arrive a year or more after the work. Practices need the program to pay its way before reconciliation.
Quality gaps close late
Blood pressure control and diabetes measures get chased at year end, when there’s little time left to change the reading.
Programs That Fit
Programs That Move Benchmarks and Bill Fee-for-Service
Each program is reimbursed by Medicare fee-for-service to the member practice that bills it, and each one targets a cost or quality lever your contract is scored on.
Remote Patient Monitoring
Continuous blood pressure, glucose and weight data for the conditions that drive admissions and quality scores.
CPT 99453, 99454, 99457, 99458
Advanced Primary Care Management
A monthly primary care bundle with no time thresholds, which suits practices already organized around a care team.
HCPCS G0556, G0557, G0558
Transitional Care Management
Contact within two business days of discharge, medication reconciliation and a timely follow-up visit.
CPT 99495, 99496
| What your contract is scored on | Program that moves it | How |
|---|---|---|
| Controlling high blood pressure | RPM | Readings between visits, medication changes made sooner |
| Diabetes control | RPM + CCM | Glucose trends plus monthly care-plan follow-up |
| All-cause readmissions | TCM + RPM | Contact in 2 business days, home monitoring for 30 days |
| Total cost of care | CCM / APCM for rising risk | Monthly contact before patients become high-cost |
| Patient experience | All programs | A named care team that calls every month |
ACO REACH and LEAD dates from CMS’s LEAD announcement as reported by Healthcare Dive and TechTarget; MSSP participation from CMS’s 2026 program figures as reported by Fierce Healthcare. HealthArc isn’t an ACO and doesn’t take risk; we run the care management your participants deliver.
How It Runs
One Program Across Every Member Practice
The ACO sets the protocols. Each member practice keeps its own billing and NPI. Our clinical team fills the gaps where a practice can’t staff the work.
Network rollout
- Shared protocols and alert thresholds
- Practice-by-practice onboarding, one contract
- Each practice bills under its own NPI
- Works across different EHRs in the network
Staffing where it’s missing
- Our nurses cover practices with no care manager
- Practices with staff can run it themselves
- Mix models site by site
- Same documentation standard everywhere
Network reporting
- Enrollment and adherence by practice
- Quality-measure gaps by attributed patient
- Readmissions and ED visits for enrolled cohorts
- FFS revenue generated per practice
Start with the rising-risk tier. The top 5% is usually already managed. The next 15% is where monthly contact changes the cost curve.
Evaluating Vendors
What ACO Leaders Ask Before Choosing a Care Management Partner
Questions from ACO executives, medical directors and MSO operators, with plain answers.
| The question | Our answer |
|---|---|
| Are you an ACO enablement company? | We’re an execution partner. We don’t take risk or share savings. We run RPM and care management across your network. |
| Can different member practices use different EHRs? | Yes. Each practice connects its own EHR, and the ACO sees one network view on our platform. |
| Who gets the fee-for-service revenue? | The member practice that bills the code. Many ACOs use that revenue to fund the program at the practice level. |
| Does this work in MSSP and ACO REACH? | Yes, and in LEAD from 2027. The care management work is the same whichever model you’re in. |
| Can you report on our quality measures? | We report blood pressure control, diabetes indicators, readmissions and enrollment by attributed patient and practice. |
| How fast can we roll out? | The first practices are typically live in about 30 days, then we add sites in waves. |
Implementation
First Practices Live in About 30 Days
Pilot with a few member practices, prove the numbers, then roll out across the network.
1
Week 1
Pick the cohort and the practices
We use your attribution file to find rising-risk patients with hypertension, diabetes or heart failure, then pick the pilot practices.
2
Week 1–2
Set network protocols
Your medical director signs off on thresholds and escalation paths. Each pilot practice connects its EHR.
3
Week 2–4
Enroll and ship devices
Our team enrolls patients under each practice’s name and ships activated cellular devices.
4
Month 2 onward
Report and expand
Monthly network reporting on quality gaps, utilization and revenue, then the next wave of practices.
FAQ
ACO and Value-Based Care Organization Questions
What ACOs and value-based groups ask us most when they start evaluating care management partners.
How does remote patient monitoring reduce total cost of care in ACOs?
By finding problems between visits. Blood pressure, glucose and weight readings flag patients who are getting worse while there’s still time to adjust treatment in the office. Fewer of them reach the ED or an inpatient bed, and that utilization is where most ACO savings come from.
What happens to ACO REACH participants after 2026?
ACO REACH ends on December 31, 2026. Participants can apply to CMS’s LEAD model, which runs from 2027 to 2036, move to the Medicare Shared Savings Program, or leave ACO models.
Can ACO member practices bill CCM and RPM?
Yes. Participation in an ACO doesn’t stop a practice billing fee-for-service care management codes. The practice bills under its own NPI and keeps the revenue.
What is the difference between HealthArc and an ACO enablement company?
ACO enablement companies usually take on risk alongside you and share in savings. HealthArc doesn’t. We provide the platform and the clinical team that deliver between-visit care, which works with an enablement partner or without one.
Which patients should an ACO enroll first?
The rising-risk tier: patients with uncontrolled hypertension, diabetes or heart failure who aren’t yet high-cost. They respond to monthly contact, and they qualify for RPM and CCM.
Who We Serve
Built for Other Kinds of Organizations Too
Get Started
Model the Program Against Your Attributed Population
Share a de-identified attribution summary. We’ll show the eligible cohort, the FFS revenue it would generate and the measures it would move.
- Eligible patients by condition and practice
- FFS revenue by member practice
- Quality measures the program reaches
- Rollout plan for your network
Schedule a Demo
Estimate Your Revenue
HIPAA Compliant • SOC 2 Certified • No long-term contracts
sales@healtharc.io • +1-201-885-5571
sales@healtharc.io • +1-201-885-5571
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How Can HealthArc Help You?
Want a demo, or just have a question about remote care in your practice? Send us a few details and a remote care specialist will get back to you shortly.
- RPM, CCM & 7 more CMS programs
- Automated time tracking & CPT billing
- Two-way EHR integration
- Managed care team, or your own
- Pre-configured cellular devices shipped
- Live in about 30 days
HIPAA compliant SOC 2 Type II No long-term contracts
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