How to Implement Value-Based Care With Remote Monitoring

Key Takeaways

• Value-based care implementation comes down to three operational steps: identify high-risk patients, enroll them, and build reporting around the data you collect.
• RPM and CCM are fee-for-service codes. If a patient is attributed to a capitated, global-budget, or full-risk contract, you generally do not bill those codes for that patient at all.
• Under a value-based contract, the return on monitoring is cost avoidance and quality performance, not a claim.
• Most practices run a hybrid panel, billing RPM codes for some patients while running identical monitoring for value-based patients where no code is submitted.
• 45.2 percent of U.S. healthcare payments now flow through value-based arrangements, and CMS wants every Traditional Medicare beneficiary in an accountable care relationship by 2030.

What is Value-Based Care Implementation?

Value-based care ties payment to patient outcomes and total cost of care instead of the number of services you bill (visits, tests, procedures). In simple terms, that's the value-based care definition: a payment model built around results, not volume.

Value-based care implementation is what it takes to actually operate under that value-based care model — building the workflows, staffing, and reporting systems needed to meet the terms of an outcomes-based contract.

That work involves a few core pieces:

• Know which patients carry the most risk.
• Track their health between appointments.
• Report in a way that satisfies your payer contracts.
• Staff the program with people who can act on the data.

Most practices move into value-based care gradually rather than all at once. They run a hybrid model for a while, billing fee-for-service for some patients and value-based contracts for others, while they build the infrastructure.

Remote monitoring is one of the fastest ways to build it.

Fee-for-Service vs. Value-Based Care

Fee-for-service pays you per visit, test, or procedure, so more services mean more revenue, regardless of whether the patient actually got healthier.

Value-based care reverses that model. Your payment depends on quality measures, patient outcomes, and how much it costs to get there, which is why the two approaches reward very different behavior.

As per the latest data available, 45.2 percent of U.S. healthcare payments now flow through value-based arrangements — a clear sign of the growth of value-based care nationwide.

CMS has also set a goal of having 100 percent of Traditional Medicare beneficiaries in an accountable care relationship by 2030, a target that's accelerating CMS value-based care adoption and pushing more of these contracts into the market each year.

Providers who wait too long to build value-based infrastructure will have less time to adjust once their own contracts change.

Types of Value-Based Care Models

"Value-based care" covers several different contract structures, and the one you are under determines how remote monitoring gets paid for.

These are the value-based care models you are most likely to encounter:

Most practices do not sit in just one of these. You might hold a shared savings contract with one payer, a Medicare Advantage capitated arrangement with another, and straight fee-for-service for everyone else.

That is why the first question about any RPM patient is not whether monitoring helps them, but which contract they fall under, because that determines whether the work generates a claim or protects a cost target.

How Remote Patient Monitoring Supports Value-Based Care Strategies

A remote patient monitoring program gives you a continuous stream of the following data between visits:

• Blood pressure
• Glucose
• Weight
• Oxygen levels
• Anything else that matters for that patient's condition

That data lets you catch problems early, before they turn into an ER visit or a hospital stay. This is where RPM connects directly to value-based care, turning value-based health care from a contract requirement into a daily workflow.

Under a fee-for-service model, a hospital admission is just another billable event. Under a value-based contract, that same admission is a cost that goes into your shared savings or triggers a penalty.

So when RPM flags a spike in blood pressure or a drop in oxygen levels before it becomes an emergency, you protect both the patient and the total cost of care number your contract is judging you on.

Your reimbursement under these contracts depends on quality scores like MIPS, HEDIS, and Medicare Advantage star ratings. RPM data feeds those scores directly.

Patient Identification and Risk Stratification for RPM Under Value-Based Care Programs

Not every patient needs remote monitoring, and trying to enroll everyone wastes time and resources. The goal is to identify patients for whom monitoring makes the biggest difference — and getting this step right is one of the most overlooked strategies to implement value-based healthcare, since misidentifying candidates wastes staff time on patients who won't benefit.

This matters across the full range of organizations and value-based networks served — ACOs, primary care groups, and specialty practices all need a repeatable way to find these patients before they can enroll them.

Which Patients Qualify for Remote Monitoring

A patient qualifies for RPM if they meet Medicare's billing requirements and fit the clinical picture RPM is built for. The billing requirements below are what gate a fee-for-service claim.

If the patient sits under a value-based contract where you are not billing RPM codes, clinical fit is what matters, and the thresholds become internal quality standards rather than payment conditions.

Billing requirements (all must be true):

• They have an FDA-cleared device that transmits data automatically. Manual entry does not qualify.
• They can generate at least 16 days of readings in a 30-day period.
• They have given documented consent before you start billing.

Clinical fit (a patient is a strong candidate if):

• They have a chronic condition such as hypertension, diabetes, heart failure, or COPD, or they are recovering from a recent acute event or surgery.
• They have the support to use the device consistently, whether that is the patient themselves or a caregiver.

If a patient meets the billing requirements but not the clinical fit, for example, they cannot use the device without help they don't have, RPM likely will not add much value for them.

Related programs:

• Chronic care management runs under a related but separate set of codes, generally for patients with 2 or more chronic conditions expected to last at least a year.
• Remote therapeutic monitoring covers non-physiological data like pain, mobility, or medication adherence. This program allows patients to self-report instead of requiring an automatic device.

Risk Stratification Methods and Data Sources

Once you know who is eligible, rank who needs monitoring the most. A few methods work well together:

• HCC risk scores: CMS assigns each diagnosis a risk weight and sums them to a single score per patient. A higher score means CMS itself expects that patient to cost more to treat, which makes this a fast way to sort your full patient list before you look at anything else.
• Claims data: Look at how often a patient has already used the ER or been hospitalized. Frequent use in the past 6 to 12 months is one of the strongest signs that a patient will need it again, so it pushes them toward the top of your monitoring list.
• EHR data: Recent labs, current medications, and the latest vitals tell you how well a condition is actually controlled right now. A patient with a high risk score but well-controlled labs may need less monitoring than one with a lower score whose numbers are trending the wrong way.
• Social determinants of health: Ask whether the patient has reliable transportation, stable housing, and consistent access to food. A patient who struggles with these is more likely to miss appointments and let a condition slip, even if their clinical numbers look fine today. So this moves them up the list.

Common Stratification Mistakes to Avoid

A few mistakes show up repeatedly, and most of them come from leaning on one data source too heavily.

Relying only on claims data misses patients whose risk is building but has not shown up in a hospital bill yet.

Focusing only on your highest cost patients means missing the "rising risk" group, the ones trending toward a crisis who could still be redirected.

And treating your risk list as a one-time exercise rather than updating it regularly means you miss changes in a patient's condition.

Patient Outreach and Enrollment in Remote Monitoring Programs

Identifying the right patients only gets you halfway there. If they never enroll, none of that stratification work pays off, so outreach has to be just as deliberate as the identification process.

How to Run an Enrollment Outreach Campaign

Start with the visits you already have on the calendar. Annual wellness visits, chronic condition checkups, and a patient's first visit after a hospital stay are all good moments to bring up monitoring.

If you cannot catch someone in person, a phone call or a portal message works just as well. Keep your message simple. Tell the patient what the device does and what it will cost them.

For patients you bill fee-for-service, Medicare Part B covers 80 percent of RPM services, so they only pay the remaining 20 percent unless they have supplemental coverage. Patients under a value-based arrangement where you are not submitting RPM claims usually have no separate cost-sharing at all, which makes for an easier conversation. Either way, check which side the patient falls on before you quote a number, and tell them upfront.

Consent and Onboarding Requirements

CMS requires documented consent before you bill for RPM. Even when you are not billing RPM codes for a value-based patient, documenting consent and enrollment is still worth doing, since it protects you if that patient's attribution changes and it supports your quality reporting. That consent needs to cover a few specific points:

• The patient is enrolling in the program.
• Only 1 provider can bill for RPM services per month.
• What their cost-sharing looks like.

Written consent holds up better than verbal consent in the event of an audit, so it is worth the extra few minutes at enrollment.

Once consent is documented, onboarding shifts to the device itself. A cellular device that does not need wifi or a smartphone app removes a lot of friction, especially for older patients who might otherwise struggle with setup.

Tactics to Improve Enrollment Rates

Devices that arrive pre-configured and ready to use cut down on the back-and-forth of setup calls. Short, plain explanations of the benefit work better than a long technical pitch.
Additionally, following up with patients who show early signs of disengagement, rather than waiting for them to drop off entirely, keeps enrollment from sliding over time.
Most practices lean on a partner's clinical monitoring and support services to handle this step, since coordinating consent, device shipping, and onboarding calls across a full patient panel is a significant staffing lift on its own.

How RPM Supports Value-Based Care Reimbursement

How RPM pays off depends on which contract a patient falls under, and this is where most practices get tripped up. RPM and CCM are fee-for-service codes. If a patient is attributed to a value-based arrangement — a capitated contract, a global budget, or a full-risk ACO track — you generally are not billing those codes for that patient at all. The monitoring is already funded through the contract.

So the reimbursement question splits in two.

For patients you still bill fee-for-service, RPM has its own codes, and the reimbursement adds up. Here are the rates compiled from the Medicare Physician Fee Schedule:

• Setup and patient education (CPT 99453) pays around $19.73.
• Device supply with at least 16 days of data (99454) pays about $43.02.
• Time spent managing that data, billed under 99457 and 99458, adds roughly $47.88 for the first 20 minutes and $41.42 for each additional 20 minutes.

New 2026 codes, 99445 and 99470, lower the data threshold to as few as two days. This opens RPM billing to lighter-touch monitoring that previously did not qualify.

For patients under a value-based contract, none of those codes are the return. The return is cost avoidance and quality performance. An admission you prevent is money that stays inside your cost target instead of eating your shared savings. That is the actual reimbursement mechanism, and for a high-risk patient, it can be worth considerably more than the fee-for-service codes would have been.

This is why the hybrid period matters. Most practices are billing RPM and CCM codes for one part of their panel while running the same monitoring workflow for value-based patients where no code gets submitted. The clinical work is identical. Only the payment path changes, so you need to know which patients sit on which side before you build your billing process.

On the fee-for-service side, stacking RPM with chronic care management lets you manage more of a patient's chronic conditions within a single program, with each service billed and documented separately. On the value-based side, you still run both workflows, but the documentation exists to support quality reporting and attribution rather than a claim.

Either way, that RPM data feeds your quality reporting. Fewer hospitalizations and better blood pressure or glucose control show up in your MIPS and HEDIS scores. Those scores are what shared savings and risk-based contracts are built on, which is why the monitoring keeps earning even when no RPM claim goes out the door.
If tracking and documenting all of this manually feels like a lot, that's exactly what dedicated RPM billing and reimbursement support is built to handle.

How KangarooHealth Supports Value-Based Care Implementation

Building all of this from scratch takes time that most practices do not have. KangarooHealth's clinical monitoring and support services are among the value-based care solutions built around the three steps above.

Here's how our platform supports each of those steps:

Patient Identification and Stratification Tools

We work with practices and value-based care networks to identify which patients qualify for RPM, RTM, CCM, or PCM programs based on their chronic conditions, so your staff doesn't have to build a stratification process from scratch.

Outreach, Enrollment, and Onboarding Support

Our team handles device procurement and trains your providers and staff on enrolling patients and getting them comfortable with their devices.

You can also keep monitoring in-house with your own staff if you prefer more control.

Billing and Reimbursement Support

KangarooHealth tracks monitoring time and generates the documentation you need, whether that is a fee-for-service claim or the quality and utilization reporting your value-based contracts run on. We can also help connect your practice with 3rd-party billing partners for claims submission on the patients you do bill.

Setup typically takes under 2 weeks, though most practices see meaningful results from their remote patient monitoring program within 2 to 3 months as enrollment ramps up.

If you want a walkthrough of what this looks like for your practice, you can talk to our team.

The Future of Value-Based Care

CMS is pushing more contracts toward shared financial risk. Under this model, you and CMS agree on a cost target for treating a group of patients over the course of the year.

If you keep costs under that target through better care, you receive a share of the savings. If costs go over the target, you may owe some of the difference back.

A few real programs show this shift already happening:

• TEAM: A new mandatory program that started in January 2026. It sets a fixed cost target for certain surgeries, covering both the procedure and the recovery period.
• LEAD: ACO REACH (Accountable Care Organization Realizing Equity, Access, and Community Health) is a Medicare program that lets provider groups take on this kind of shared financial risk. It winds down in 2026, and a new 10-year program called LEAD is replacing it in 2027, built to help smaller and rural practices take part in these risk-based programs.
• Proven results: In its most recent performance year (PY), the Medicare Shared Savings Program saved Medicare $2.5 billion. Physician-led practices generated $319 in net savings per patient, well above the $180 generated by hospital-led practices.

The takeaway is that more of your future contracts will set a cost target like this. Practices that already track patient data closely, the way RPM lets you do, have a much better shot at staying under that target.

Frequently Asked Questions (FAQs)

Below are a few frequently asked questions surrounding this topic:

Can You Bill RPM and CCM Under a Value-Based Care Contract?

Usually not. RPM and CCM are fee-for-service codes, so if a patient is attributed to a capitated contract, a global budget, or a bundled payment episode, the monitoring is already funded through that arrangement and no separate claim goes out.

The exception is shared savings. Under upside-only and most two-sided ACO tracks, you continue billing fee-for-service as normal, and the savings calculation sits on top, so RPM and CCM codes still apply. Check the specific contract before you build a billing workflow around either assumption.

Can You Bill RPM and CCM in the Same Month?

Yes. CMS allows RPM and chronic care management to be billed for the same patient in the same month, because they cover different work.

What you cannot do is count the same minutes toward both, so your documentation has to keep the time separate.

What Is the Difference Between RPM, RTM, and CCM?

All three are separate programs with separate codes, and they cover different work:

• RPM covers physiologic data such as blood pressure, glucose, weight, and oxygen levels, and it requires an FDA-cleared device that transmits readings automatically.
• RTM covers non-physiologic data such as pain, mobility, and medication adherence, and it allows the patient to self-report instead of requiring an automatic device.
• CCM covers care coordination for patients with 2 or more chronic conditions expected to last at least a year. It involves no device at all.

If you are deciding which program fits a patient, our remote patient monitoring and chronic care management pages break down the requirements for each.

Does RPM Data Count Toward MIPS?

Indirectly, and significantly. RPM is not itself a MIPS measure, but the outcomes it drives feed measures you are already scored on, including controlling high blood pressure and diabetes control. Running a monitoring program can also support improvement activity credit.

This is the part that carries over to value-based patients. Even when no RPM claim is submitted, the data still moves your quality score, which is what shared savings and risk-based contracts are settled on.

How Much Does RPM Reimburse?

For fee-for-service patients, the current Medicare rates are:

• Setup and patient education (CPT 99453): around $19.73.
• Device supply with at least 16 days of data (99454): about $43.02.
• Management time (99457 and 99458): roughly $47.88 for the first 20 minutes and $41.42 for each additional 20 minutes.

New 2026 codes, 99445 and 99470, lower the data threshold to as few as two days, which brings lighter-touch monitoring into the billable range. Rates vary by locality, so check the Medicare Physician Fee Schedule for your area.

How Long Does It Take to Implement a Value-Based Care Program?

Full value-based care transformation can take years. RPM-specific programs move much faster.

For fee-for-service patients, billing can start the same month a patient meets the required data threshold. For value-based patients, where you are not billing RPM codes, the payoff shows up later, once lower utilization and better quality scores land in a performance year. Most practices see program results within 2 to 3 months of launch.

What Devices Are Used for Remote Patient Monitoring?

Common devices include blood pressure cuffs, glucose meters, pulse oximeters, weight scales, and medication adherence sensors.

For billing purposes, the device needs FDA clearance and must transmit data automatically, not rely on the patient to enter readings by hand.

What Are the Key Value-Based Care Quality Measures?

The value-based care quality measures used in these contracts include:

• MIPS scores providers across quality, cost, interoperability, and improvement activities.
• HEDIS measures things like screenings and chronic condition control.
• Medicare Advantage star ratings factor in both outcomes and patient experience.

Can Small Practices Implement Value-Based Care?

Yes, and the data backs that up. Physician-led ACOs with lower revenue per enrollee outperformed hospital-led ACOs in savings in CMS's most recent program year.

Joining an existing ACO, or using tools like RPM to build value-based capabilities gradually, gives smaller practices a realistic path in.

Conclusion

You only need 3 things to start moving into value-based care: identify the right patients, get them enrolled, and build the reimbursement and reporting structure around the data you collect.

Remote patient monitoring gives you a direct path through all three. With the right support behind it, a program that once felt out of reach for smaller practices becomes a realistic value-based care strategy for value-based care providers of any size.

That is where a partner like KangarooHealth helps. You don't need to build this alone or hire a new team to run it.

When you work with us, our clinicians monitor your patients under your brand, and we support RPM alongside other reimbursable programs like CCM, so you are not locked into a single revenue stream as your value-based contracts grow.

If you want to see how this would work for your practice, you can schedule a demo with our team.