A clinician-led primary and remote care group ran three Medicare programs across three disconnected systems, reconciling billing by hand every month. We built one platform unifying Advanced Primary Care Management, Remote Patient Monitoring, and Behavioral Health Integration across six roles, five web portals, and a patient mobile app, with billing logic the founding physician validated himself.
Talk to UsA clinician-led primary and remote care group serving rural and underserved hospitals and clinics
APCM, RPM, and Behavioral Health unified across six roles, five web portals, and a patient mobile app
FHIR (US Core), OAuth 2.0, iOS
In active development
This is a capability result, not a measured-outcomes one. The platform is in active development, and no enrollment volume, claims-approval rate, or revenue figure is available from the source record.
The clinic could not answer basic questions about its own programs because the answers lived in different systems, and Medicare's payment rules for advanced primary care land in the data model, not the reporting layer.
Patients created by hand fell out of sync with the EHR record, producing duplicates and mismatches. Since the patient record determines billing eligibility, a bad record became a claims problem, not a data quality one.
Program eligibility was verified when the bill went out rather than when the patient was enrolled, the more expensive point to catch a problem.
Medicare pays for advanced primary care as a monthly bundle only if the practice can evidence consent obtained before services start, 24/7 access to patient information, an electronic care plan, care transition follow-up within seven days of discharge, population-level risk stratification, and performance measurement.
Built on FHIR-based EHR integration with per-clinic OAuth credentials and a native iOS patient app.
We evaluated APCM eligibility at the service level rather than as a single yes or no, resolved against the patient's live condition list rather than captured once at signup.
We defined six roles with clear boundaries: super admin, clinic admin, physician, nurse, digital health navigator, and patient. The digital health navigator got its own portal as a first-class role, since CMS permits auxiliary personnel to deliver these services incident to the billing provider under general supervision.
Care plans show the current value against target rather than a percentage-complete bar, tied to the patient's assigned device. Patient messages route through AI triage first, escalating to a nurse or physician as severity requires, with every escalation labeled with what raised it.
The clinic dashboard leads with enrollment effectiveness, eligible against enrolled and the conversion gap, with RPM engagement, clinical outcomes, and HEDIS-aligned quality measures beneath. The platform integrates with each clinic's EHR over FHIR and OAuth, configured per clinic with its own credentials, base URL, organization ID, and scopes.
Talk to us about what it takes to build the eligibility and consent layer so that billing holds up.
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