For health plans
RBYS operates as the on-the-ground clinical extension of your plan, meeting members at the hospital bedside, driving them home, and managing the 30 days that determine whether they're readmitted. Fee-for-service, PMPM, or shared-savings structures available.
Nearly one in five Medicare patients is readmitted within 30 days of discharge. Most of those readmissions trace back to the same gap: medication confusion, missed follow-ups, and the absence of anyone physically present during the first week home. The clinical knowledge isn't missing. The tools aren't missing. The person on the doorstep is.
RBYS operates as a vertically integrated in-home care provider: transportation, clinical visits, and longitudinal care management under one organization, one workflow, one phone number.
01 / Single team
No third-party hand-offs between transport, clinical, and care management vendors. The EMT-licensed crew that picks up the member at the hospital is part of the same team that does the in-home visit and the daily check-ins. Continuity is operational, not coincidental.
02 / Physically present
An EMT walks into the home. A clinician joins by video for the visit, or arrives in person for higher-acuity cases. Either way, vitals are taken in the room, the medication cabinet gets opened, and the family conversation happens face to face. Not a portal message. Not a phone call.
03 / Operationally proven
The fleet, the routes, the dispatch infrastructure, and the relationships with hospital case management teams are not new. The clinical service is the extension of an established operating company, not a startup learning logistics on your members.
04 / Local concentration
We are not a national vendor with thin coverage. We operate Greater Orlando intensively. Every member in our panel is within a 45-minute drive of our home base. Response times reflect that.
05 / Community-rooted
Our EMTs, clinicians, and care managers come from the neighborhoods we serve. Members see staff who speak their language, recognize their culture, and know their churches and pharmacies. Engagement rates reflect that. Engagement is the leading indicator for every downstream outcome.
Why this matters
Engagement rate is the leading indicator for every downstream outcome. Readmissions, ED utilization, cost of care. None of it moves if the member won't open the door.
Clinical infrastructure is necessary but not sufficient. The difference between a member who engages and a member who declines a visit usually comes down to whether the person on the doorstep feels like part of their community. Not an outside vendor sent by the insurance company.
National vendors arrive. We are already here. Our EMTs grew up in Oviedo. Our care managers worship in Apopka. Our team speaks Creole in the homes that need it. That isn't marketing. It's the operating advantage that determines whether a member opens the door.
01 / Local hiring
Our EMTs, clinicians, and care managers are recruited from Greater Orlando. Same accents, same neighborhoods, often the same churches and corner stores as the patients on our panel.
02 / Language fluency
Trilingual staffing is not a checkbox. It reflects the Medicaid and dual-eligible population we serve, including a large Haitian and Caribbean Latino community whose care often falls through cracks when language fails.
03 / CBO relationships
Food banks, faith-based caregivers, AAAs, and neighborhood pharmacies. The actors that close social-determinant-of-health gaps that clinical care alone cannot.
04 / Continuity of relationship
Members don't see a rotating cast. The EMT who picks them up at discharge is often the same one driving them to dialysis the following week. Familiarity is a clinical asset.
Community partnerships Active relationships with organizations across Greater Orlando
Our service is designed for high-acuity, high-utilization members. The ones who account for a disproportionate share of total cost of care and where in-home intervention has the largest measurable impact.
Post-discharge transitional care, chronic care management, and remote patient monitoring for MA members with two or more chronic conditions.
CPT 99495 / 99496 · 99490 / 99491 · 99453–99458
Coordinated benefit navigation across Medicare and Medicaid, including behavioral health integration and social-determinants support.
Model of Care–aligned · HRA integration available
Care coordination for high-utilization members, behavioral health integration, and non-emergency medical transport to specialty appointments.
Florida AHCA-licensed · 1915(c) waiver eligible
Post-surgical recovery management and high-cost claimant programs for self-funded employer plans and commercial members with catastrophic risk.
Case-rate or per-episode pricing available
Every service maps to a defined Medicare or Medicaid billing pathway. The list below is what your plan will see on encounter data.
Partner plans receive a monthly outcomes report against the metrics below. Reporting begins at the close of the first full month after go-live, with comparison against the agreed-upon baseline established during contracting.
From hospital discharge to first in-home visit. The one number we commit to upfront. Measured and reported on every member, every month.
48 hrs
Designed to integrate with your existing care management platform, your delegated entities, and your prior authorization process. Not replace them.
01 / Referral
Direct intake from your care management team via secure portal, HL7 feed, or direct phone line. Average response under 2 hours.
02 / Engagement
Bedside or home visit scheduled within 48 hours. Family contacted. Member onboarded to monitoring devices if RPM-eligible.
03 / Ongoing care
Daily check-ins, monthly care plan reviews, and escalation pathways back to plan-aligned PCP and specialist network.
04 / Reporting
Encounter data, quality metrics, and risk-adjusted cost reporting delivered on a monthly cadence in your preferred format.
Data exchange
HL7 v2 · FHIR R4 · SFTP · CSV
Compliance
HIPAA · HITRUST-aligned · BAA standard
EHR integrations
Epic · Cerner · Athena · custom
We are open to fee-for-service, capitated, and value-based structures. Most partnerships start with a defined pilot population before scaling.
01 · Fee-for-service
Standard claims pathway for plans that prefer a transactional structure. Useful for testing the model with a small population before expanding.
Encounter-level billing · No upfront commitment
02 · PMPM capitation
Predictable cost structure with full clinical responsibility for the enrolled population. Most commonly used by Medicare Advantage and D-SNP partners.
Risk-adjusted · Quarterly true-ups
03 · Shared-savings
For plans ready to share both savings and risk. Typically structured as a 50/50 split against a risk-adjusted total cost of care benchmark.
Upside-only or two-sided · Annual reconciliation
Greater Orlando: Orange, Seminole, Osceola, and Lake counties. We operate from a single hub in Orlando. Members outside our service area are not currently in scope; expansion to adjacent counties is on our 2026 roadmap.
Current active panel is 1,200+ members. Capacity to scale to approximately 5,000 active members by the end of 2026 with planned clinical and operational hiring. Beyond 5,000, capacity expansion would be addressed in the contracting conversation.
Typical timeline from signed agreement to first member enrolled is 60 to 90 days, depending on data integration complexity and credentialing. Pilot programs with a defined member list can move faster: 30 to 45 days.
Yes. We offer fee-for-service, capitated PMPM, and shared-savings structures. Two-sided risk is available for partners with sufficient panel size to support actuarial soundness: typically 500+ attributed members.
RBYS follows plan-specific prior authorization requirements for any service that requires it. Our care management team works directly with your UM team to expedite authorizations for time-sensitive transitions like TCM visits.
Clinical leadership bios available on request. Our medical director is a Florida-licensed physician with prior leadership experience in value-based primary care. Full leadership and credentialing dossier shared under MNDA during contracting.
Partnerships
Schedule a 30-minute call with our partnerships team. We'll walk through your member population, the outcomes you're trying to move, and whether RBYS is the right operational fit.