G0558 · APCM
Dual-eligible / QMB share
- Patients
- 211
- Rate / mo
- $117.24
- Annual
- $296,922
Built for FQHC care operations
Turn every eligible patient into accountable monthly care.
IHA Care gives FQHCs one operating layer to identify opportunity, organize monthly work, supervise exceptions, and prepare review-ready evidence—without replacing the EHR or transferring practice authority.
2-minute assessmentNo patient dataImmediate implementation path
IHA Care · Operations command
Live workflowMonday · monthly care cycle
Good morning, operations team.
- Panel assessed
- 5,000100%
- Candidates
- 1,142+84
- Evidence ready
- 96%+3.2%
Prioritized work
17 openCare due
12 patients
Clinical review
3 exceptions
Ready for billing
28 packets
Supervision
4
Exceptions routed to named owners
No unowned alerts
Review-ready evidence is visible before billingPractice retains final authority
Works beside your EHR
No replacement project
APCM is not time-threshold billed
All requirements still apply
Flexible staffing
Your team or IHA navigators
Practice keeps authority
Clinical, coding, and claims
Interactive calculator
Estimate the opportunity in your panel.
Adjust the assumptions to build a planning estimate. Eligibility, service requirements, documentation, and rates must still be validated patient by patient; the practice’s billing team makes the final determination.
Interactive planning tool
Practice opportunity calculator
Start with three practice-level numbers. The result estimates only the additional patients between current and target enrollment—not revenue from patients already enrolled.
Incremental estimate
Illustrative annual gross from the enrollment gap
$51,227 per month
Modeled only for the increase from 4% current enrollment to 25% target enrollment.
- Modeled eligible panel
- 3,350
- Incremental patient gap
- 704
67% chronic-condition share
30% dual-eligible / QMB proxy
Uses practice-level assumptions only. No patient information is requested or needed.
Your practice
3 inputsTotal Medicare patients attributed to the practice, including dual-eligible patients.
%
Current share of eligible patients enrolled in care-management services.
%
The share your practice could support with an organized monthly-care workflow.
Planning estimate only—not a reimbursement forecast. Eligibility, documentation, billability, and rates require patient-level review by the practice.
Implementation decision
Choose how the program runs.
Compare the operating model—not just the gross reimbursement estimate. You can refine staffing and rate assumptions below.
- Incremental gross annual
- $614,730
- Staffing expense
- $375,000/ yr
- Incremental contribution after modeled cost
- $239,730
- Care-management capacity
- 5 modeled FTEs
FTE need is a planning estimate and may be met with existing or new staff. Actual capacity varies with acuity, workflows, supervision and program requirements.
This is not practice net income. It excludes platform and implementation pricing, supervision, RCM and denial effects, overhead, patient cost sharing, payer variation, and uncollected amounts. Those inputs belong in the FQHC-specific implementation brief.
In either model, your FQHC retains clinical supervision, the EHR, coding, claims submission and final compliance authority. The IHA-supported model still requires named practice owners for supervision, escalation and billing review; actual internal resource needs vary.
Assumptions and exclusions
FTE need is a planning estimate and may be met with existing or new staff. Actual capacity varies with acuity, workflow, supervision, and program requirements.
This is not practice net income. It excludes implementation, supervision, RCM and denial effects, overhead, patient cost sharing, payer variation, and uncollected amounts.
Your FQHC retains clinical supervision, the EHR, coding, claims submission, and final compliance authority.
Refine the modelStrategy, QMB share, staffing, fee and code assumptions
Care model
APCM-first is the default because it organizes eligible care around monthly service requirements rather than a minutes-first workflow.
The model assigns G0557 to the non-QMB share and G0558 to the QMB share as planning assumptions. The practice must validate eligibility and tier selection.
%
The model uses G0558 for this share as an assumption; eligibility and tier selection require practice review.
Staffing assumptions
Refine the capacity and cost assumptions behind the practice-team model.
Actual capacity depends on acuity, workflow design, supervision, staffing and program requirements.
Salary, benefits and practice overhead for a care coordinator or CHW.
Detailed model output
Published rates and internal planning assumptions are shown separately. Billing authority and final coding remain with the practice.
Illustrative incremental contribution after staffing
$239,730/ year
G0557 · APCM
2+ chronic, non-dual
- Patients
- 492
- Rate / mo
- $53.78
- Annual
- $317,808
- Incremental gross annual
- $614,730
- Care-team FTEs
- 5
- Staffing / yr
- $375,000
APCM inputs use CMS CY 2026 national non-facility rates: G0557 $53.78 and G0558 $117.24. Actual payment, eligibility and cost sharing vary and must be validated. See the CMS FQHC/RHC payment-rate source. The optional CCM-first view uses an internal illustrative $78 planning blend—not a single CMS rate and not an assertion that services may be billed together. The model assumes 67% of Medicare beneficiaries have 2+ chronic conditions (CMS chartbook estimate). QMB protections, service requirements, documentation and billing compatibility must be verified against current CMS and MAC guidance before billing.
Clear operating boundaries
What IHA handles—and what your FQHC controls.
IHA handles
- Workflow configuration
- Navigator operations where contracted
- Billing-evidence preparation
- Exception visibility and operational reporting
Your FQHC controls
- Clinical supervision and standard of care
- The EHR and clinical record
- Coding and claim submission
- Final legal and compliance decisions
Responsibilities are documented during implementation. IHA is designed to support elements described in OIG compliance guidance; it does not certify compliance or replace the FQHC’s counsel, compliance program, or billing authority. Actual arrangements require practice counsel and compliance review.
The working platform
From panel to packet.
Each step creates the input the next person needs. Exceptions stay visible until someone owns them.
- 01
Find the right patients
Map eligibility, program fit, QMB evidence, and conflicts from the panel.
- 02
Run the monthly work
Give each navigator a ranked list of care, outreach, and coordination actions.
- 03
Supervise exceptions
Route clinical needs, missing evidence, and quality review to the right owner.
- 04
Prepare the evidence
Hand billing a transparent packet of supported and withheld lines.
No account required. Follow a synthetic patient from panel review to payment-ready evidence.
Take the guided product tourCommunity-to-care continuity
Trusted outreach should lead to sustained care.
Many FQHCs already work with churches, community organizations, and trusted navigators. IHA Care helps the receiving practice turn those connections into accountable intake, enrollment, monthly work, and follow-through under FQHC supervision.
Trusted community connection
A patient reaches care through a relationship they already trust.
FQHC-owned intake and enrollment
The practice confirms fit, consent, eligibility, and ownership.
Accountable monthly care
Approved teams work from visible priorities and escalation rules.
Visible outcomes and follow-through
Open needs stay owned through review, evidence, and next action.
The relationship opens a door. The FQHC owns the care.
Community partners do not make clinical, coding, or billing decisions. IHA Care is not a paid referral network, and partnership compensation is never based on patient referrals or claims.
What you can verify today
Proof before promises.
See the product, operating boundaries, and implementation controls before discussing production activation.
- Working synthetic product tour
- Eleven implementation-readiness gates
- Practice-controlled authority model
- Synthetic validation before activation
- Documented compliance and escalation boundaries
- Review-ready implementation plan
Practical implementation
Start with the practice you already have.
Configure the operation around your current team, EHR handoffs, supervision, policies, and billing partners—not a forced software conversion.
- 01
Readiness
Map the panel, staffing, EHR handoffs, supervision, and billing workflow.
- 02
Configuration
Approve roles, permissions, consent, escalation, documentation, and review rules.
- 03
Validation
Test the full workflow with synthetic records before any live patient work.
- 04
Activation
Begin with an approved cohort and expand only when practice leadership is ready.
Sequence and timing vary by panel quality, systems, staffing, approvals, and organizational readiness.
Risk and compliance
Reduce preventable risk. Never pretend to transfer it.
The practice remains responsible for the care it supervises and claims it submits. IHA Care makes workflow, ownership, evidence, and exceptions visible before billing.
Consent gates claim readiness
Patient facts support APCM tier review
QMB evidence remains visible
Configured conflicts are flagged
Care-plan history is preserved
Human and AI-assisted actions are attributable
Designed around OIG guidance. Never “OIG approved.”
IHA supports written workflows, accountable roles, monitoring, auditing, and corrective action. OIG’s general guidance is voluntary and nonbinding; it does not replace legal advice or the practice’s compliance program.
Read the OIG guidanceTwo operating models
Add the platform—or add capacity with it.
Choose the same governed operating system for your existing team, or contract for IHA-supported navigator capacity under your FQHC’s supervision.
Platform for your existing team
Your staff performs the care-management work in a configured IHA Care workspace.
- Workflow and role configuration
- Synthetic-data training and launch support
- Evidence preparation and operating reports
IHA-supported navigator capacity
Contract for navigator operations without transferring clinical, coding, or claims authority.
- Navigators work from approved playbooks
- Exceptions follow practice-controlled escalation
- Fixed-fee structure—not collections share
Your readiness review
Leave with a practical first-step plan.
The review clarifies fit and implementation. It does not imply guaranteed enrollment, revenue, compliance, or that a fee structure alone establishes legality.
- Panel opportunity map
- Staffing and operating-model comparison
- First-cohort implementation sequence
- Safeguard and authority map
Questions practices ask
What needs to be true before you say yes?
Does IHA Care replace our EHR?
No. Your EHR remains the clinical system of record. IHA Care runs the care-management operation beside it: panel identification, enrollment, monthly work, supervision, safeguards, and billing evidence.
Is this only an APCM product?
APCM is the operating default because it is billed monthly rather than against a time threshold and fits longitudinal primary care. Every applicable monthly service and coding requirement still applies. CCM, CHI, PIN, RPM, and social-needs workflows remain available when the patient and program requirements call for them.
Who performs the care-management work?
Your existing team can use the platform, or IHA can provide trained navigators under the practice’s clinical supervision. Roles, escalation, review, and billing ownership are defined before production use.
Who makes the final billing decision?
The practice and its billing team do. IHA prepares the operational evidence and shows unsupported or conflicting lines; it does not submit claims or take a percentage of collections.
Does the platform make us OIG compliant?
No software can certify or transfer an organization’s compliance responsibility. IHA Care is designed to support compliance-program elements described in OIG guidance, including written workflows, accountable roles, monitoring, audit history, and corrective-action evidence. The practice and its counsel retain final authority.
How does implementation work?
We map the current panel, EHR and billing handoffs, staffing model, consent process, supervision, and safeguards before configuring the workspace. The public product tour shows the operating sequence; a readiness review turns it into a practical plan for your sites and teams.
See how IHA Care fits your practice.
Bring the questions your clinical, operational, compliance, and billing leaders need answered. We’ll show the working system and map the panel opportunity, operating model, first cohort, and authority safeguards.