Enroll ≥ 1,500 eligible Medicare patients in CCM + RPM, cut all-cause admissions in enrolled cohort by ≥ 25%, and capture ≥ $90 PMPM net revenue so the program self-funds.
Enroll ≥ 1,500 eligible Medicare patients in CCM + RPM, cut all-cause admissions in enrolled cohort by ≥ 25%, and capture ≥ $90 PMPM net revenue so the program self-funds.
Eligible Patients Identified from — to ≥ 4,000 (monthly). Enrolled Patients (signed consent + care plan) from 0 to ≥ 1,500 (weekly). Enrollment Conversion (eligible → enrolled) from — to ≥ 38 (monthly).
16 weeks.
Integrates with CCM/RPM platform (Cadence / Optimize Health / Validic / Vivify), Cellular-enabled BP cuff, weight scale, glucometer, pulse-ox, EHR integration for vitals + time tracking (Epic Healthy Planet / Cerner HealtheRegistries), Billing system charge-capture for monthly CCM + RPM codes through the AEROSS Execution Mesh. All writes are credit-metered, CAPS-gated, and audit-stamped.
CMS CCM codes 99490 / 99439 / 99487 / 99489 — non-face-to-face minutes per calendar month; CMS RPM codes 99453 (setup) / 99454 (device) / 99457 (first 20 min) / 99458 (each addl 20 min); OIG Special Fraud Alert (July 2022) — beneficiary consent, eligibility, no waived cost-share; HIPAA — RPM device data is PHI; BAA with vendor required; Beneficiary cost-share applies (not waivable); document affordability discussion All agent actions inherit AEROSS CAPS governance — autonomy ceilings, human approval gates, and a tamper-evident audit log.