New The evidence for between-visit care: what monthly check-ins do for Medicare patients — read the research →
AI care team · Medicare primary care

An AI care team for Medicare patients, between visits.

Alli calls and texts your patients on your behalf every month, catches problems early, and writes everything directly into your EMR. A member of our care team reviews every flag. Medicare pays for it. Your day doesn't change.

12 / year
check-ins per patient
100%
flags human-reviewed
Zero
new software for you or your patients
Exhibit 01 — The call 0:00
AlliHi Margaret, it's Alli from Dr. Lee's office for your monthly check-in. Is now still a good time?
PatientOh yes, hello dear. Now's fine.
AlliLast month you mentioned your knee was bothering you on the stairs — how's it been?
PatientBetter, actually. The exercises the doctor gave me are helping.
CARE-PLAN FOLLOW-UP · KNEE — IMPROVING · LOGGED
AlliThat's wonderful. And your blood pressure — do you have a recent reading?
PatientThis morning it was 152 over 88. That's a bit high for me.
BP 152/88 · ABOVE 3-MONTH TREND → FLAGGED
AlliThank you for checking it. Any dizziness or lightheadedness since we last spoke?
PatientA little, when I stand up quickly.
NEW SYMPTOM · ORTHOSTATIC DIZZINESS → FLAGGED
AlliI'll make sure the team sees both of those today. And your refills — do you have enough of everything?
PatientI'm nearly out of the metformin, come to think of it.
REFILL REQUEST · METFORMIN → ROUTED TO OFFICE
AlliDone — the office will call it in. You'll get a reminder before your visit with Dr. Lee on the twelfth. Take care, Margaret.
CHECK-IN DOCUMENTED · CARE PLAN UPDATED · NOTE FILED
Simulated call · synthetic voice · unmute to listen NOTE FILED TO EMR
Integrates directly with your EMR

Notes, flags, and care-plan updates are written straight into the chart. No portal to log into, no new software to learn — for your team or your patients.

EpicathenahealtheClinicalWorksNextGenVeradigmTebraAdvancedMDElationDrChronoPractice Fusion+ yours
Why Alli

Outbound. Medicare-first. Invisible to your workflow.

Most practice AI waits for the phone to ring. Alli picks it up — reaching the patients who would never call, about the things that matter most between visits.

01 · Outbound, not inbound

We start the conversation.

Scheduling bots and front-desk agents handle the patients who call in. Alli reaches the ones who don't — every month, on your behalf — and brings back what it finds.

02 · Built for Medicare

The patients with the most at stake.

Chronic conditions, long medication lists, and the highest cost of a missed warning sign. Medicare also funds the work, so better care and a stronger practice point the same way.

03 · No new software

A familiar number. Your own chart.

Patients hear from Alli the way they've always heard from your office — a call or a text from a trusted number. You read the result in your EMR. Nobody logs into anything.

4%

Almost nobody gets this care.

Only about 4% of eligible Medicare beneficiaries ever received chronic care management — not because the medicine didn't work, but because the operations didn't. Medicare now pays for between-visit care without the minute-counting. Alli does the operations. The other 96% is why we exist.

SOURCE: CMS CLAIMS ANALYSIS · SEE PAPER 03 — "THE END OF MINUTE-COUNTING"
Exhibit 02 — The escalation

What happens when something's wrong.

On the left, the moment. On the right, everything that happens before it reaches you — and what lands in your hands.

The moment · during a monthly call
Margaret T. · monthly check-in2:14 PM
AlliIs there anything else that's been bothering you since we last spoke?
Patient"…my ankles have been swelling all week, but I didn't want to bother anyone about it."
AlliI'm glad you told me. I'll make sure Dr. Lee's team hears about this today.
What happens next · before it reaches you

Flagged in seconds

The exact words, documented, and checked against the escalation criteria and risk assessments your practice defines. No advice given, no reassurance offered — Alli's job is to catch, not to judge.

Reviewed by a human

A member of Alli's care team reads the transcript against Margaret's history and trend. Urgency separated from noise before anything reaches you.

Delivered to your practice

Escalation · same dayAlli → Dr. Lee's team
Margaret T. — new bilateral ankle swelling, 1 week. Transcript and trend attached.
Your channel of choicePhoneSecure faxEmailEMR note
You decide · outcome written to the EMR · next check-in knows
Exhibit 03 — The paper trail

Every conversation becomes a compliant record.

Between-visit care has real documentation requirements. Alli captures consent, keeps the care plan current, writes every note to the chart, and hands your biller a clean file at month end.

Consent record
PatientMargaret T.
ProgramExplained in plain language
Consent✓ Captured & documented
Filed toPractice EMR

Before a single check-in happens, enrollment consent is captured and written into the chart.

Monthly note
TouchpointVoice call · 4 min
SummaryGlucose ↑, refill needed
Flags2 → human review
Written to✓ EMR · care plan updated

Transcript, structured summary, and flags — written to the EMR automatically after every conversation.

Billing file
PeriodMonth end
Requirements✓ Tracked per patient
CodesAssigned per patient, per month
Delivered toYour biller

A billing-ready export your practice or billing company ingests. Your practice bills; Alli never does.

Exhibit 04 — Quality

Built for practices in ACOs.

The same monthly conversation closes care gaps and captures the measures your ACO reports on. Each item below is a question Alli can ask, document, and act on — configured to your measure set.

Care-gap closure

Screenings, labs, eye exams, vaccines — asked about on the call, scheduled when overdue, logged when done.

Depression & falls screening

Annual PHQ-2/9 and falls-risk questions, administered by voice and documented to the chart.

Home blood pressure

Readings captured between visits, so hypertension control isn't judged on one office number a year.

Medication adherence

"Are you still taking it?" — the stopped statin or metformin, caught and routed before the next visit.

Annual Wellness Visit scheduling

Alli books the AWV and the follow-ups — attribution, care plan, and problem list kept current.

Post-discharge check-ins

A call within two business days of a hospital or ED discharge, with anything concerning escalated same day.

Social needs screening

Food, transport, and housing questions — asked by a voice patients actually answer.

Quality reporting back to you

Structured answers written to the EMR and summarized for your quality team, configurable to your ACO's measure set.

Configurable to your ACO's measure set · MSSP, REACH, and commercial value-based contracts · Alli asks and documents; your clinicians decide

Exhibit 05 — The economics

The relationship pays for itself.

Medicare reimburses monthly between-visit care through its Advanced Primary Care Management program. Alli does the work for a flat fee; your practice bills Medicare and keeps the rest — and the value of each patient relationship grows over time.

One patient · growing value over time
01
EnrollAlli reaches patients the month they turn 65 — and the ones who've drifted away — and brings them into your care.
Live
02
Check inA monthly call or text, every month. Problems caught early, consent and care plan kept current, notes in your EMR.
Live
03
Keep wellCare-gap closure, wellness-visit scheduling, and post-discharge follow-up for the patients who need it most.
Live
04
Go deeperBehavioral-health screening and follow-up, layered onto the same monthly relationship.
Next
Illustrative revenue — your panel
500 enrolled patients
1001,000
$300,000
per year
$25,000
per month

Illustrative only. CY2026 national Medicare rates for monthly between-visit care, blended patient mix (~$50/patient/mo), before Alli's flat fee. Actual reimbursement varies by locality and mix. Your practice bills Medicare and owns all billing decisions; Alli never bills Medicare or practices medicine.

Exhibit 06 — The guardrails

Powerful because it's careful.

The rules are absolute, and they're the reason physicians trust Alli with their patients.

Alli never

  • ✕Gives medical advice. Not a recommendation, not a reassurance, not a dosage. Ever.
  • ✕Makes clinical decisions. Judgment belongs to your clinicians. Alli asks, documents, and escalates.
  • ✕Bills Medicare. Your practice owns billing, end to end.
  • ✕Replaces a visit. Check-ins surface what needs you sooner — they never substitute for you.

Alli always

  • ✓Operates under a signed BAA. HIPAA Business Associate; encrypted in transit and at rest. SOC 2 in progress.
  • ✓Keeps a human in the loop. Every flag is reviewed by a member of our care team before it reaches your practice.
  • ✓Documents everything. Every word, every flag, every outcome — in your EMR, against your patient.
  • ✓Runs isolated per practice. Your patients' data lives in your instance. No pooling, no sharing.
What the evidence says

The case for between-visit care isn't ours. It's the literature's.

Programs with frequent contact, medication management, and transitions support reduced hospitalizations — while low-touch telephone programs without them repeatedly failed.

The care-management literature
Synthesized in Paper 01

Physician-led, primary-care-dominant ACOs generated $403 in net per-capita savings — roughly 1.8× their hospital-centric counterparts.

Medicare Shared Savings Program
Most recent results · Paper 02

CMS redesigned care management into APCM explicitly "to reduce the administrative burden associated with current coding and billing."

CMS · Federal rulemaking
CY2025 PFS · Paper 03
Read the full evidence series →
Company

Built by operators, for independent primary care.

Alli is a New York–based company building the care team we wished our own parents' doctors had. We're hiring — see open roles.

Investors

Alli is backed by its founders and raising a seed round. For the deck, model, and data room, write to us directly.

Request the data room
Exhibit 07 — Talk to us

The best proof is a conversation.

Twenty minutes with our team. We'll model your panel's numbers, walk your workflow, and dial a live check-in so you can hear exactly what your patients would.

Your panel's illustrative economics, modeled with you
A live check-in call — the voice, the pace, the warmth
The escalation path and paper trail, end to end

Prefer email? hello@allihealth.ai

We reply within one business day by email, or by phone if you asked us to. No spam, no mailing lists.