Services
It all starts with Provider Advocacy
Citadel advocates for independent primary care providers by acting as a liaison between payers and practices, leveraging close relationships to extend support. Resolving credentialing, claims, and payment issues and ensuring practice visibility with major payers are just a few of the benefits of joining the 225+ providers partnering with Citadel.
Payer Contracting Support
Access top-tier reimbursement rates built specifically for independent primary care, with broad payer coverage across all major lines of business, including commercial, Medicare Advantage, Medicaid, and more. Citadel advocates for secondary contracts like lab and ancillary services to drive improved care and increase revenue, providing value across the system.
Strategic Partnerships
Citadel’s partnerships with industry leaders open the door for independent practices to access enterprise-level support. Through strategic alliances with partners like Aledade and more, Citadel connects practices with a network of support and resources to enhance business sustainability.
Digital Care Management
Programs are Fully Turnkey.
Citadel seamlessly extends practice capabilities by handling:
Enrollment
Monitoring
Documentation
Compliance
Billing
Advanced Primary Care Management (APCM)
Expand between-visit care offerings to include patients with only one chronic condition, improving health outcomes for even more patients with no additional burden to staff.
What Makes APCM Different
- Patients are eligible with just one chronic condition
- Expands patient participation
- Drives more consistent monthly revenue
- Extends preventive care reach
How APCM Impacts Your Practice
Improved Clinical Outcomes
Patients enrolled in APCM have an almost
70% reduction in ER utilization
Operational Relief
Lowers staff burnout and extends practice
capabilities without introducing new systems
Higher Patient Satisfaction and Loyalty
Proactive between-visit outreach increases quality of life and builds patient trust and retention
Increased Revenue
Scale revenue by over $100K annually with 300 patients enrolled
Remote Patient Monitoring (RPM)
Use real-time health data to catch trends before they become hospitalizations.
How RPM Impacts Your Practice
Improved Clinical Outcomes
One Citadel practice with over 750 patients enrolled saw a 7-point reduction in systolic blood pressure averages after four months
Patient Satisfaction
Citadel averages 32% patient enrollment (national benchmark is 22%)resulting in more patients with improved health outcomes
More Data With No Additional Burden
Enrolled patients average 23.6 reading days/month
(national benchmark is 15.3), leading to better chronic disease management without introducing new staff or systems
Increased Revenue
- See a 20% average increase in Medicare revenue
- Scale revenue by over $135,000 annually with 250 patients enrolled
Chronic Care Management (CCM)
A seamless extension of your team that helps provide quality between-visit care for patients with multiple chronic conditions.
How CCM Impacts Your Practice
Improved Clinical Outcomes
Patients not enrolled are almost 3 times more
likely to visit the ER
Patient Satisfaction
Extends practice capabilities and reduces burden on
staff without introducing new team members or systems
More Data With No Additional Burden
Improved health outcomes increase quality of life and engagement, driving higher patient satisfaction and loyalty
Increased Revenue
Scale revenue from $100K–$500K
annually based on patient enrollment
Payer Contract Negotiation
Top-tier rates, built for independent primary care with broad payer coverage across all major lines of business and growing secondary contracts, including lab ancillary billing.
Our goal is increased value across the system, driven by improved quality of care and reduced referrals and overall cost.
Chronic Care Management (CCM)
Simplify Chronic Care. Improve Patient Outcomes. Increase Revenue.
At Citadel Health, we believe in empowering independent primary care practices in Georgia to deliver exceptional chronic care management (CCM) without adding to your workload. Our comprehensive CCM program seamlessly integrates into your practice, allowing you to focus on what matters most: your patients.
CCM is a Medicare-supported service that offers the support patients with multiple chronic conditions need to live healthier, more fulfilling lives. Designed to bridge the gap between office visits, the program empowers patients to better manage their health while reducing hospital visits and improving overall outcomes. Our Citadel Health team manages every aspect of the program so your team can focus on patient care, not paperwork.
How CCM Impacts Your Practice
Built for independent primary care with broad payer coverage across all major lines of business and growing secondary contracts, including lab ancillary billing.
Advanced Primary Care Management (APCM)
Advance Patient Care. Improve Health Outcomes. Increase Practice Revenue.
At Citadel Health, we believe in empowering independent primary care practices in Georgia to deliver Medicare-supported Advanced Primary Care Management (APCM) without adding work to your team. Our program functions as a seamless extension of your practice, so you can focus on in-office care while we drive between-visit support, documentation, and compliant reimbursements.
APCM is designed to broaden access to care management services through new patient tiers, meaning more of your Medicare panel can qualify—creating a larger eligible population than traditional CCM models and unlocking additional recurring revenue for your practice.
How APCM Impacts Your Practice
Better Outcomes + Less Avoidable Utilization
- Patients not enrolled in Citadel’s Digital Care Management (DCM) programs—including APCM—are nearly 3x more likely to visit the ER
- The total medical spend of patients enrolled in our DCM programs is ~60% of the spend of patients not enrolled
- Team-based care strengthens hypertension and diabetes control
- Monthly check-ins increase medication adherence and follow-through
Higher Patient Satisfaction and Loyalty
- Improved health outcomes increase quality of life
- Proactive outreach builds trust and retention
- Patients feel “cared for” between visits, not just at visits
Operational Relief
- Reduces inbound patient call volume
- Lowers staff burnout by offloading routine monitoring
- Seamlessly integrates with your EMR
- Extends practice capabilities without introducing new staff or systems
Increased Revenue
- Citadel specialist handles documentation, compliance, and billing so you don’t have to
- Earn an additional $25,000 annually with 75 enrolled patients
- Scale revenue by over $100,000 annually with 300 patients enrolled, with additional upside in ACO/shared savings programs
Why Practices Are Pivoting from CCM to APCM
More patients can qualify
More revenue per patient panel
Because eligibility expands via tiers, practices can:
- Enroll more of their Medicare/MA panel
- Generate more consistent monthly revenue
- Grow without hiring additional staff
APCM introduces tiered eligibility, which means you can include:
- Patients who need between-visit support but didn’t fit cleanly into traditional CCM workflows
- Patients across different complexity levels, not just one “CCM bucket”
Patient Tiers
TIER 1
General Primary Care Management Support
- Medicare patients who benefit from structured, between-visit support (care navigation, coordination, preventive and chronic condition follow-through).
- Ideal for patients who need help staying on track but may not fit a traditional “high-complexity” bucket.
TIER 2
Chronic Condition / Moderate Complexity Management
- Medicare patients with ongoing clinical needs (often multiple chronic conditions) who require more frequent coordination, monitoring, and care plan follow-through.
- Supports longitudinal management between office visits and helps reduce gaps in care.
TIER 3
High Complexity / High Utilization Risk
- Medicare patients who are dual eligible (Medicare + Medicaid) and Qualified Medicare Beneficiaries (QMB) who require high-intensity, team-based support between visits.
- Often includes patients with multiple chronic conditions, social and access barriers, higher care fragmentation risk, and greater need for care coordination, medication support, and referral/follow-up management.
- Designed for the patients most likely to benefit from proactive monthly touchpoints to help reduce avoidable utilization and close care gaps.
Remote Patient Monitoring (RPM)
Streamlined Data Tracking. Optimized Care. Better Health Outcomes.
Citadel Health’s Remote Patient Monitoring (RPM) program supports primary care practices by giving patients the tools to manage their chronic conditions at home while keeping providers updated in real time. Improve patient outcomes and experiences with the aid of smart technology and our dedicated support.
RPM enables providers to monitor trends proactively and adjust care plans as needed using securely collected and transmitted real-time health data, preventing unnecessary hospitalizations.
How RPM Impacts Your Practice
Improved Clinical Outcomes
- One Citadel practice with over 750 patients in the program saw a 7-point reduction in systolic blood pressure averages after four months of enrollment
- Patients not enrolled in Citadel’s Digital Care Management (DCM) programs—including RPM—are nearly 3 times more likely to visit the ER
- The total medical spend of patients enrolled in our DCM programs is ~60% of the spend of patients not enrolled
More Data With No Additional Burden
- Real-time data enables early detection of health issues, quicker interventions, and enhanced clinical decision-making
- Enrolled patients average 23.6 reading days/month (national benchmark is 15.3)
- Better chronic disease management without introducing new staff or systems
Patient Satisfaction
- Citadel averages 32% patient enrollment (national benchmark is 22%)
- Improved health outcomes increase quality of life
- Compassionate, consistent communication builds strong patient relationships
Increased Revenue
- Practices implementing RPM see a 20% average increase in Medicare revenue
- Earn an additional $50,000 annually with 100 enrolled patients
- Scale revenue by over $135,000 annually with 250 patients enrolled
- Citadel specialist handles documentation, compliance, and billing so you don’t have to
Strategic Partnerships
Our partnerships with industry leaders, like Aledade and more, ensure that you get the top selection of options, whether we’re connecting with ACOs or streamlining reporting.
