Role Switch
Role Switch

Close gaps in risk share of savings

Value-based care depends on a comprehensive understanding of every patient. TeleMEDix delivers clinical clarity across the patient journey so you can identify every relevant condition, improve risk-adjustment accuracy, close quality gaps, and earn shared savings — without manual chart review.

$540K

Gross incremental revenue per practice

$412K

Net profit after staff & platform costs

9.5x

Return on platform investment

75th

Quality percentile, up from the 40th

The problem

Volume-to-value moves practices into two-sided risk

The Medicare Shared Savings Program and ACO arrangements reward practices for keeping patients healthy — but they also introduce downside risk. Legacy EHRs were built to bill for visits, not to track chronic-disease trajectories. So the programs that would earn shared savings — CCM and RPM — sit unused, and the practice carries the risk without the tools to manage it.
Risk Diagram
VOLUME · FFS VALUE · VBC UPSIDE Share the savings DOWNSIDE Repay CMS Which way you go depends on the tools you have.

What "two-sided risk" really means

In an upside-only contract, doing nothing simply leaves money on the table. In a two-sided track, if costs run over the benchmark, the practice can owe money back to CMS. The difference between earning savings and writing a check is whether you can find every condition, close every gap, and prevent avoidable admissions — at the whole-panel scale.

Every device and app captures a slice of the picture, but none of them share a record — so no one sees the whole patient.

USE CASE

The programs exist, they just never get executed

A typical five-physician practice, 2,000 lives, already has the billing codes and the devices. Here’s what actually happens to them:

CCM – available

Tracked on spreadsheets

20 of ~400 eligible enrolled

Code 99490 is reimbursable today, but time tracking by hand doesn’t scale, so most eligible patients are never enrolled.

RPM — available

Devices unused in a closet

0 patients actively monitored

RPM devices were purchased but never deployed — no workflow to ingest readings or act on alerts.

ADT — arriving

Faxed, checked weekly

48-hour follow-up window missed

Discharge alerts land on a fax machine. By the time anyone reads them, the transitional-care window has closed.

The result

Faxed, checked weekly

48-hour follow-up window missed

Discharge alerts land on a fax machine. By the time anyone reads them, the transitional-care window has closed.
VBC solution

One system for risk stratification ,HCC capture, and quality-gap closure

TeleMEDix unifies the chronic-care workflow. Four connected capabilities turn the same staff and the same panel into captured revenue and higher quality. Here is what each one does — and what it looks like in practice.

AI Risk Engine Mock Card
AI Risk Engine · Today's priority worklist
Dr. Danna's panel · 12 patients need action
Maria G., 67
Discharged 36h ago — TCM window open
ADT
James T., 71
Home BP trending 158/94, rising 5 days
RPM
Sarah M., 54
18 min CCM logged — 2 min to bill 99490
CCM
Robert K., 63
A1c overdue 4 months
Gap

AI Risk Engine

Tells staff who needs attention, what they need, and when

The optimizer runs quality-gap campaigns on their own, tracks closure across the whole panel, and routes each open item into a staff worklist — so gaps get closed before they hit your quality score.

Use case

James T.’s home blood pressure climbs to 158/94 over five days. The engine flags him today — not at his annual visit six months from now — so a nurse intervenes before it becomes an admission.

VBC Optimizer Mock
VBC Optimizer · Quality-gap campaigns
Diabetes A1c campaign · auto-running
A1c screening — 42 patients due
78% closed
33 gaps closed9 in outreach
A1c overdue — Robert K.
Auto-added to outreach
Order
Mammogram — Lisa P.
Reminder sent
Outreach
BP control — James T.
Recheck scheduled
Review

VBC Optimizer

Closes quality gaps and captures shared-savings drivers automatically

The optimizer runs quality-gap campaigns on their own, tracks closure across the whole panel, and routes each open item into a staff worklist — so gaps get closed before they hit your quality score.

Use case

Robert K.’s A1c is four months overdue. Rather than surfacing at year-end, he’s automatically added to the diabetes campaign and an order is queued — one of 33 gaps closed this quarter without manual review.

VBC Optimizer Mock
VBC Optimizer · Quality-gap campaigns
Diabetes A1c campaign · auto-running
A1c screening — 42 patients due
78% closed
33 gaps closed9 in outreach
A1c overdue — Robert K.
Auto-added to outreach
Order
Mammogram — Lisa P.
Reminder sent
Outreach
BP control — James T.
Recheck scheduled
Review
HCC / RAF Dashboard Mock
HCC / RAF Dashboard · Pre-visit suspects
Surfaced from labs, meds & history — ready to document
CKD Stage 3 — Maria G.
eGFR 48 on last two labs
+0.32 RAF
COPD exacerbation — James T.
2 rescue-inhaler fills, dyspnea note
+0.28 RAF
Diabetes w/ complication — Sarah M.
Neuropathy documented, uncoded
+0.31 RAF
Estimated pre-visit RAF value~$10.1K

HCC / RAF Dashboard

Surfaces every documentable condition before the visit

TeleMEDix reads labs, medications, and history to suggest HCC conditions the record supports but no one has coded yet — structured for risk adjustment and defensible on audit, across the whole panel rather than just complex cases.

Use case

Maria G.’s last two labs show an eGFR of 48, consistent with CKD Stage 3 — but it was never coded. It’s surfaced before her visit, documented in seconds, and adds +0.32 to her risk score.

Longitudinal Lifetime Medical Record Mock
Longitudinal Lifetime Medical Record Mock
6 sources across payers — assembled & deduplicated
Hospital A · Epic Clinic B · athena Reference lab Payer claims One patient record FHIR R4 · C-CDA · normalized
Duplicates merged, gaps reconciled
Continuous across payers — assembled in minutes
Live

Longitudinal Lifetime Medical Record

Anchors every patient to one record across payers and sites

Longitudinal lifetime medical record assembles data from every care site and payer into a single longitudinal record, normalized to FHIR R4 and C-CDA. It sits above your existing systems with zero rip-and-replace, so documentation stays consistent and defensible across the panel.

Use case

A new patient arrives with history spread across six prior care sites. Longitudinal lifetime medical record pulls it together, deduplicates it, and hands the clinician one clean record — in minutes, not after weeks of records requests.

Longitudinal Lifetime Medical Record Mock
Longitudinal Lifetime Medical Record Mock
6 sources across payers — assembled & deduplicated
Hospital A · Epic Clinic B · athena Reference lab Payer claims One patient record FHIR R4 · C-CDA · normalized
Duplicates merged, gaps reconciled
Continuous across payers — assembled in minutes
Live
What it looks like in a real practice

Same staff. Same panel. ~$540K more revenue.

A five-physician primary care practice with 2,000 lives in an MSSP Enhanced track — 12 to 18 months on TeleMEDix.

Before TeleMEDix

20 CCM patients

Spreadsheets. RPM in a closet. ADT faxed and checked weekly. 40th percentile. Zero shared savings.

After · CCM

400 patients

~$168K · code 99490

Automatic time tracking and one-click compliant billing.

After · RPM

200 patients

~$18K · 99454 + 99457

Active monitoring with real-time ADT and 48-hour follow-up.

After · VBC

75th percentile

~$192K value-based

HCC, avoided admissions, MA Star, and MIPS — now earning shared savings.

Revenue Breakdown Chart Card

Where the ~$540K comes from

Gross incremental revenue, stacked by source
CCM $168K RPM $18K VBC $192K TOTAL GROSS ~$540K

VBC revenue = HCC capture, avoided admissions, MA Star, and MIPS combined.

Quality Percentile Chart Card

Quality percentile

Panel quality score, before vs. after
40th Before 75th After

Download TeleMEDix Beta

TeleMEDix Beta is now open for early access on iOS and Android. Experience AI-powered health monitoring, secure telehealth, medication tracking, referrals, and seamless medical record collaboration—built for both Patients and Providers.

From daily activity and wearable data to medication adherence and telehealth updates, TeleMEDix brings your health journey into one intelligent view. Share real-time insights with your care team and make faster, better-informed decisions. Be among the first to experience connected digital care.

Be among the first to experience connected digital care.

Bring Clarity to Your Data. Work More Effectively with Your Patients. Capture More Revenue!

A 30-minute demo with our team. No prep required — we use a sample patient record and show you exactly how it works.

Bring Clarity to Your Data. Work More Effectively with Your Patients. Capture More Revenue!

Frequently asked

How does TeleMEDix support HCC coding accuracy?

TeleMEDix assembles a comprehensive longitudinal record across care sites and payers and applies its clinical engine to surface every relevant condition. An HCC/RAF dashboard structures the output for risk-adjustment programs, and documentation stays consistent across the whole panel.

Can TeleMEDix surface and close care gaps?

Yes. The value-based-care optimizer runs quality-gap campaigns automatically and tracks closure across the panel, routing identified gaps into staff workflows rather than leaving them in unstructured notes.

How does TeleMEDix protect against downside risk?

By reducing preventable utilization. Real-time ADT with 48-hour follow-up, RPM monitoring and intervention, and utilization tracking help avoid admissions — a documented driver of the example practice’s shift to earning shared savings at the 75th percentile on quality.

Medical Disclaimer
i

Medical Disclaimer

This platform provides evidence-based clinical decision support...

This platform provides evidence-based clinical decision support recommendations to assist healthcare providers and patients. It does not replace professional medical judgment, diagnosis, or treatment. Final clinical decisions and responsibility for patient care remain with the licensed healthcare provider.

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