About one in five Medicare patients is readmitted within a month. You — their own practice — are best placed to prevent it, and Medicare pays $20–40K a year to do it. The documentation bar is why most never collect. This app clears it.
New prescriptions that don't match the old list. A follow-up that never gets booked. That's the path from recovering to readmitted — and it runs through the weeks that land on your desk.
Medicare patients are back in the hospital within 30 days. The practice that knows them is best placed to stop it.
Miss one element and the whole episode pays nothing. That's why this work drifts to health-system teams meeting your patient for the first time.
A real two-way check-in — logged and timestamped, not implied.
7 days for high complexity, 14 for moderate. In person or telehealth.
Reconciliation, follow-up, and the coordination that prevents a readmission.
Every element present, mapped line by line to the code you bill.
No care-management department to build. The app watches every deadline and assembles the record. Your practice just sees the patient.
Your patient appears on the worklist with the clock already running.
The app reaches your patient in your practice's voice — every touch timestamped.
Scheduling tracks both windows so the right code is earned, not guessed.
An audit-ready record, mapped to the code. You review and submit.
“The thirty days after discharge are when patients slip. This is the first tool that actually helps me catch them — and document it properly so it counts.”
Once a patient leaves the hospital, their own doctor usually never finds out if they went back. For thirty days, Transitions of Care watches — pulling from the hospital and the health plan — and tells you what happened.
If your patient was readmitted, you find out and can act. If they stayed well, that outcome is confirmed — the thing you most want to know about a patient you just sent home, and the thing you normally never learn.
A clean 30-day window is what the episode turns on. We confirm it against real hospital and plan data before you bill — so what you submit is backed by the outcome, not an assumption.
Your practice can't see this. PanelMD can — because it sees your patient across every source, not just what happened in your office. That's the superpower Transitions of Care runs on.
Medicare pays this because a readmission costs far more.
National averages. Actual rates vary by locality and payer.
Medicare pays for this because the care works — catching a patient in the first thirty days is what keeps them out of the hospital. You're finally getting paid for the safety net you should already be running.
States standing up rural care-transitions networks are funding provider onboarding. Register during a funded window and Transitions of Care stays free for your practice — forever, in writing.
Standard registration stays open everywhere — no funding required.
The follow-up you should already be running — cleared, documented, and worth $20–40K a year.
Register your practiceLeave your details and our team will reach out to get you set up — usually within a day.