Remote Patient Monitoring, a True Sustainable Solution for FQHCs and RHCs

While healthcare innovations have transformed the industry, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) have often been left behind. Without Medicare support for many remote care initiatives, their patients, providers, and leaders have struggled to find sustainable solutions to complex challenges.

For years, FQHCs and RHCs faced barriers to adopting innovative care solutions like remote patient monitoring (RPM). Limited funding, staffing shortages, and outdated reimbursement models made it difficult to provide continuous care outside the clinic walls. 

In 2025, CMS expanded that access , prompting many organizations to seriously evaluate whether remote care programs are:

1. Worth the investment and
2. As effective as companies like ours claim

But don’t worry. We'll address both concerns as we walk you through the details of RPM and the aspects of a remote care program you need for success and sustainable growth. 

In this guide, we’ll cover:

• What is Remote Patient Monitoring (RPM)?
• DIY Solutions vs. Full Service RPM Solutions
• Key Benefits of Remote Patient Monitoring for FQHCs and RHCs
• How RPM Works 
• Choosing the Right RPM Technology 
• Problems We Aim to Solve
• Billing and Coding for FQHCs

What is Remote Patient Monitoring (RPM)?

RPM is a solution for providers to see into the “black box” of the home—something remote monitoring technology has made possible like never before. Cellular or Bluetooth technology is used in biometric devices to upload patient data into a database or your health system’s EHR/EMR. 

It’s the use of health monitoring technology to support what happens in a clinical setting. From medication changes to emergency care, all are impacted by the continuity of care provided by regular readings outside the walls of the community health center.

Between remote patient monitoring, chronic care management, and telehealth solutions, providers can create a comprehensive system of remote care that helps prevent acute health events with the regular, proactive monitoring of patient vitals outside of the clinical setting. 

This kind of care is especially helpful for patients impacted by one of multiple chronic diseases. An 80-year-old diabetic heart disease patient has enough to manage, so providing an easy-to-use, cellular-enabled blood pressure monitor that directly reports to their doctor’s EHR can be the thing that allows them to actually take those readings. 

DIY Solutions and Programs vs. Full Service

Most people reading this are an ambitious bunch. You are the leader/provider/administrator of a health system that might have HRSA funding or the green light to build a remote care program, and you are researching how to start. 

One thing that you’ll notice is that RPM isn’t all that complicated… until it is. 

First, you source devices.

• What kind are they?
• Do you choose Bluetooth devices that require your aging population to sync them to WiFi they might not have?
• Do you choose cellular-enabled devices that will transmit the info directly to your chosen location?

Then, you map out where all that patient health information will be stored. 

• Where do you even store that volume of data?
• Locally, on site?
• Off-site?
• How do you secure that volume of data?
• If you have to participate in an audit, can you provide documentation of secure information transfers?
• Within your EHR/EMR?

Then, you train your staff on 1) monitoring incoming data and 2) training patients on how to use their new devices. 

• Do you have the staff bandwidth or the budget to hire new staff?

All told, if you’re considering building your own remote care program, be aware of some of these considerations. 

Key Benefits of RPM for FQHCs

Providing healthcare to underserved populations is FQHCs’ bread and butter. While they might be very good at it, complications still exist—we’ll talk in-depth about these later. 

When first evaluating options for remote care programs, it helps to understand why these have become so popular for organizations across the globe. 

Improved Patient Outcomes

It doesn’t matter how cool an initiative sounds. If the program does not truly help the population you serve, it’s not worth it. Remote patient monitoring has been proven to improve patient outcomes in all kinds of patient populations facing all kinds of conditions. 

Increased Access To Care

No one wants to drive 80 miles for an hour-long doctor’s appointment. For some people, the cost of gas alone would be enough to make them skip. If the care plan compliance is dependent on a person making frequent trips to a far-away healthcare facility, you can’t be surprised when compliance is non-existent. 

RPM removes the distance barrier by bringing care directly to patients—no travel required.

Reduced Healthcare Costs

One of the biggest draws in the early days of RPM was the reduced cost of care. Now, it’s understood that that benefit is just one part of the puzzle. 

One of our clients was able to save the cost of 74 individual hospitalizations (a total of $999,000 based on an estimate of $13,500 per hospitalization). (Source) And for FQHCs, that level of saving can mean caring for that many more uninsured and underserved patients whose lives depend on your organization. 

Better Patient Engagement

Blood pressure and blood glucose readings can improve very quickly if a patient cooperates in their care. Over a period of one month, a heart disease patient can feel hopeful because their readings are showing the results of their dedication and hard work. 

For others, frequent readings can simply mean they continue to take their medications because they (and their doctor) can tell when they don’t. 

One of our participants said, “I like that I get a reminder if I miss a day, it is great to have that convenience.”

Working With Limited Staff Bandwidth

In Federally Qualified Health Centers and Rural Health Centers, there is a level of urgency that other types of organizations simply don’t experience—at least, not to the same extent. The word “federal” implies federal funding, which means leadership in these organizations are constantly facing the threat of their staff going across the street for a raise. 

That threat is doubled by the fact that all healthcare workers are constantly battling burnout. Staffing shortages don’t discriminate, and when you are federally funded, that problem is extreme. 

The point is that your team simply doesn’t want to add anything else to their work. No more clicks, no more programs, nothing! It almost doesn’t matter how good a remote care solution is because leadership will always have to fight that fact. One cannot simply ask a team of nurses at a health center to fit an extra 10-20 hours of patient monitoring work into an already full week;remote care programs, when staffed internally, require additional headcount. 

EHR/EMR Integrations

Here at Tellihealth, we can integrate with any EHR. RPM solutions are supposed to be actual solutions, and without that component, you are asking your staff to navigate two different software systems, a major point of internal contention.

Generally speaking, an optimal RPM solution will present EHR/EMR integrations as a bare minimum of the service, meaning only one program to navigate with at-home readings automatically being fed in. 

For example, here is our listing in athenahealth’s marketplace.

To leverage these benefits, it’s important to understand some of the features of an effective RPM system. 

Features of RPM for FQHCs

Here are just a handful of RPM features that can be vital for success in FQHCs:

• Real-Time Monitoring - Devices can be used to collect and transmit data instantly. Healthcare providers can respond to any abnormalities right on time. 
• Data Integration - RPM systems should have the capability to integrate with EHRs. This allows for a seamless flow of information. 
• Custom Alerts - For timely interventions, healthcare professionals can get notified using alerts about critical changes in patient health. 
• Scalability - RPM programs can expand to meet the growing needs of FQHCs. It does not matter if you are monitoring 200or 20,000 patients; RPM can adapt. 

How RPM Works in FQHCs

The process for RPM is structured to be seamless, combining patient engagement and clinical expertise with technology. Now, let's walk through a step-by-step guide to how remote patient monitoring works for FQHCs.

Patient Enrollment 

Finding patients who would benefit from RPM is the first step. Usually, this entails a thorough evaluation of a patient’s diagnosis codes.

Device Selection, Setup, and Training 

When a patient is found to be a good candidate for RPM, the FQHC will choose the right medical monitoring equipment. These devices may include weight scales, glucose meters, pulse oximeters, and blood pressure monitors. It depends on what type of readings best support their continuity of care. 

The patient will then receive the required equipment and instruction from the FQHC. Depending on your RPM partner, this might include remote instruction, written instruction, or in-person training.

Data Collection 

Patients use these RPM devices to measure predesignated health metrics. These devices are designed to be easy to use for any patient population and take the burden of “uploading” data off the patient's hands. Also, their readings will be reported back no matter the location, so your patients can even take their devices on vacation, and those readings will get back to your EHR/EMR. 

Data Transmission 

FQHC receives the collected data in a secure manner. This may happen via Wi-Fi, Bluetooth, or cellular networks—again, depending on your partner. We only use cellular-enabled devices whereby data transmission occurs automatically, lowering the possibility of errors.

Data Analysis 

Healthcare providers review the incoming data. Readings outside your predetermined parameters will be flagged, making it easier for providers to focus on patients who need immediate attention. This analysis can also highlight trends over time. 

Intervention and Patient Feedback

Providers take immediate action if the data reveals alarming patterns. They might change prescriptions or set up follow-up appointments.

During consultations, FQHCs can provide patients with insights. They can offer suggestions for improvement as well as a breakdown of how the data represents the patients' health. This is crucial in helping the patients remain motivated and involved during the process.  

Choosing “The Right” RPM Technology

We briefly mentioned before that the “right” device for your patients is important, but when selecting RPM devices, it’s essential to match the technology to the patient’s condition and your organization’s needs. For example:

• Vital signs monitoring: Blood pressure monitors, pulse oximeters, and thermometers are ideal for tracking key health metrics.
• Chronic disease management: Glucometers and ECG monitors are designed to manage specific conditions like diabetes or heart disease.
• General health tracking: Smart wearables and scales support broader or preventative health goals.

You also need to consider how the devices transmit data:

• Cellular devices: Easy to set up and widely accessible but may incur higher costs.
• Bluetooth devices: Often more affordable and integrate well with existing systems, though security concerns may arise.

Focus on compatibility with existing EHR systems and ensure devices are user-friendly for patients and providers alike. 

Problems RPM Needs to Solve

There is no point in bringing in healthcare technology, getting anyone’s buy-in, and taking steps to integrate if your “solution” isn’t helping your organization solve its problems. 

Let’s talk about some of these problems and how RPM works for FQHCs. 

Problem 1: Staff Shortages 

It’s no surprise that healthcare is facing a major staff shortage industry-wide. And it’s also no surprise that integrating any type of system into your workflow is—for a time—more work. Asking your limited staff with their limited time and resources to do anything additional is a struggle that leadership constantly faces, but we have good news. 

While that initial investment of time and energy cannot be helped, our clients very quickly find that it’s a “slow down to speed up” situation. Once that time has passed, remote care programs enable quick onboarding and are almost immediately providing high-touch care to those who need it most—removing that from the clinical setting. 

Problem 2: Lack of Medical Attention

Underserved communities are very used to not getting medical attention. Just like food deserts, rural communities must travel hundreds of miles for adequate care. Thankfully, RPM devices provide support anytime and anywhere, allowing patients to receive care without needing in-person appointments. 

Problem 3: Organizational Issues 

To say that FQHCs are big would be an understatement. There are thousands of patients, hundreds of staff, and plenty of leadership professionals. Getting them all to participate, or, at the very least, buy into the idea of a remote care program, can be tough. 

One way we can solve this problem is by requiring no upfront investment to set up an RPM program. Another way is to have a tried and true system of implementation and patient onboarding. When choosing an RPM program, we suggest working with someone with tenure and a proven track record of 1) solving your problems and 2) working with your type of patients and/or organization. 

Problem 4: Cost of Care 

Simply put, RPM for FQHCs does offer lower costs compared to in-office appointments, and it is most certainly cheaper than emergency care. By providing real-time updates as your patients take readings, a remote care program can reduce emergency visits dramatically.

Problem 5: Less Tech Savvy Patients

In healthcare, older patients and comorbidity have the most frequent care needs. The challenge is that they are also the most infrequent users of technology. 

Such patients should be given a proper introduction to the devices—something that is often provided. The devices should be user-friendly, and you can also offer written or visual instructions to the patients. 

Compliance and Reimbursement for RPM in FQHCs

Another huge roadblock to successful RPM implementation in FQHCs and RHCs is compliance. Your leaders are in charge of protecting a massive amount of PHI, and without perfectly clear workflows and claims processes, you could be risking expensive mistakes. 
 

So, one thing we recommend is having a clear understanding of existing codes and how they pertain to your type of organization. 

As of 2025, CMS has allowed for the direct use of remote care CPT codes by FQHCs, which both changes and expands their ability to provide (and be reimbursed) for remote care. 

• 99453: One-time setup and patient education (billed only once per device or episode)
• 99454: Monthly device supply + data transmission (requires ≥ 16 days of readings per 30-day period; aggregated across devices)
• 99457: First 20 minutes of interactive clinical time
• 99458: Additional 20-minute increments beyond 99457

Billing rules & notes:

• 99453 is typically billed only once per new device / episode.
• 99454 is billed once per 30-day period (even with multiple devices) as long as ≥ 16 days of readings occur.
• The “interactive communication” for 99457 / 99458 must be synchronous (two-way) and may include data review + audio/video.
• Clinical staff time used for RPM services must follow “incident to” and supervision rules under Medicare.

Success in FQHCs Is Specific 

While RPM offers several benefits for supporting FQHCs, there is no simple way to start and end implementation in that type of organization. They are special, do special work, and have extremely unique problems—but those are ones we’ve solved before. 

Please remember that a DIY system basically just makes you an RPM company, and your work is consuming enough. Also, remember that RPM systems have to present clear solutions to your most pressing problems. 

Be specific and minimal about your goals in the beginning. Prove to your clinicians that your solution (even if it requires more clicks) is going to help them provide better care. 

Are you ready to transform patient care at your FQHC? Let’s chat! 

Book a free demo today to explore the benefits of accuRPM’s turnkey RPM solution. 
 

FAQs

Who is eligible for RPM in FQHCs and RHCs?

Medicare patients with conditions that benefit from ongoing physiologic monitoring, for example hypertension or diabetes. Document clinical rationale and obtain patient consent per Medicare rules.

Do the 16 days for CPT 99454 have to be consecutive?

No. You need at least 16 calendar days of patient transmitted physiologic data in a 30 day period. The days do not need to be consecutive.

If a patient uses more than one device, how is CPT 99454 billed?

Bill 99454 once per 30 day period per patient as long as the combined data from all devices reaches at least 16 days.

How often can we bill CPT 99453?

99453 is generally billed one time per patient for a new device episode that includes setup and education. Do not bill it every month.

What counts toward the 20 minute requirement for CPT 99457?

Time spent by qualified staff or the practitioner reviewing RPM data, assessing the patient, documenting, and interacting with the patient or caregiver using two way synchronous communication within the month.

When do we add CPT 99458?

Use 99458 for each additional 20 minutes of RPM management time in the same month beyond the first 20 minutes billed with 99457.

Can we count the same minutes for RPM and CCM in the same month?

No. Minutes must be unique to each service. Do not double count time across programs.

Can FQHCs and RHCs still use G0511?

No, FQHCs and RHCs can no longer use G0511, as its use was discontinued for these providers after the transition period ended on September 30, 2025.

Do staff need direct supervision for RPM services?

Follow Medicare supervision and incident to requirements in place for your setting. Many RPM activities can be provided by clinical staff under appropriate supervision with documentation.

What consent is required?

Obtain and document patient consent before enrollment. Consent can be verbal or written per Medicare rules. Include discussion of services, cost sharing, and how data will be used.

What if a patient misses readings?

If fewer than 16 days of data are received in a 30 day period, you cannot bill 99454 for that period. You may still bill management time codes if the time and communication requirements are met.

Can RPM and RTM be billed together?

Do not bill RPM and Remote Therapeutic Monitoring (RTM) for the same patient for the same condition and time period. Choose the service that best fits the clinical need.

How do lost or damaged devices affect billing?

Supply a replacement when appropriate and continue monitoring. 99454 can be billed only once per 30 days per patient when the 16 day requirement is met, regardless of replacements.

How should we track time?

Use a reliable timer inside your platform or a standardized time log. Capture date, duration, staff member, and a short note of the clinical activity and patient interaction.

What privacy and security standards apply?

Follow HIPAA and your security policies. Use secure devices and encrypted transmission. Maintain BAAs with vendors and ensure data flows into the EHR or approved systems.

Does Medicaid or commercial coverage follow the same rules?

Coverage varies. Many payers mirror Medicare, but policies differ by state and plan. Verify benefits and coding with each payer before going live. Ask us about our eligibility service – dial 1-888-4108 or email care@tellihealth.com.

What are common reasons for denials?

Fewer than 16 data days for 99454, time that is not clearly documented for 99457 or 99458, double counting minutes across programs, missing consent, and supervision errors. Conduct periodic internal audits to prevent repeat issues, Incorrect dates of service.

Where should we start if we are new to RPM?

Define clinical use cases, choose cellular devices for ease of use, integrate with the EHR, standardize consent and documentation, pilot with a small cohort, and expand once operations and billing are stable.

What is the best way to get in touch with Tellihealth?

Dial 1-888-407-4108 or email us at care@tellihealth.com.