• 04/24/2019 4:14 PM | Anonymous

    This week, the Centers for Medicare & Medicaid Services (CMS) announced new, voluntary value-based payment models for primary care: Primary Care First and Direct Contracting. Applications are expected to open shortly and both models will begin in Jan. 2020 for a five-year period. Both are expected to qualify as advanced alternative payment models (APMs).

    • The Primary Care First model is designed for small practices and provides a monthly population-based payment, flat primary care visit fee, and a performance-based payment adjustment to incentivize reduced hospital use. There is a second payment track under this model that will focus on seriously ill patient populations.  
    • The Direct Contracting model is geared toward larger organizations with at least 5,000 Medicare beneficiaries that have experience taking on financial risk. There are three variations of the Direct Contracting model with increasing levels of risk-sharing and reward. 

    MGMA supports CMS’ efforts to create additional voluntary APMs and will work with the agency as it irons out details for each model.

    This article originally published in the 4/24/2019 MGMA Washington Connection

  • 01/29/2019 9:47 AM | Anonymous

    Medical Practice Issues to Watch in 2019

    2019 promises to be another busy year in healthcare. The 2018 midterm elections shifted the balance of power in Washington as Democrats now hold the gavel in the U.S. House of Representatives, creating a divided Congress with the Republican-held Senate. MGMA has identified the following legislative and regulatory issues critical for medical practices in the coming year. We will keep members apprised of key developments in these areas and their impact on medical practices and will continue to advocate for policies that enable practices to thrive in their mission to furnish high-quality, cost-effective patient care.

    1. HHS doubles down on risk

    Despite an anemic pipeline of new voluntary Medicare alternative payment models (APMs) trickling out of the Department of Health and Human Services (HHS), Secretary Alex Azar is planning a new approach to accelerate participation in risk-based APMs. Forgoing incremental implementation, the Secretary is expected to unveil new mandatory models in 2019 and to emphasize performance-based risk as a necessary component of any new APM.

    MGMA strongly supports voluntary participation in APMs when it makes financial sense for individual practices and disagrees with the Secretary that the way to expedite the move to value-based care is to mandate participation. We will continue to advocate for new opportunities for practices to participate in voluntary APMs and for development of more physician-led models.

    2. Regulatory relief from government burdens

    It is expected that Congress and the Administration will continue to work toward reducing the regulatory burden on medical practices participating in government healthcare programs. The Centers for Medicare & Medicaid Services’ (CMS’) “Patients Over Paperwork” initiative is one such example. However, this has translated into only modest relief for practices thus far, as 88% of MGMA members polled reported an increase in overall regulatory burden last year. MGMA will continue to make regulatory relief a top advocacy priority in 2019. Keep up with our efforts at

    3. Kicking back the Stark Law

    As part of the effort to accelerate payment innovation, HHS leaders pledge to revisit antiquated fraud and abuse rules such as the Stark Law and Anti-Kickback Statute. In 2019, watch for proposed rules that expand exceptions and safe harbors to protect value-based arrangements and benefit providers willing to take on performance-based risk. 

    While a push to simplify Medicare compliance rules is welcomed, it is likely that congressional intervention will be necessary to achieve meaningful reform. It remains to be seen if Congress will also prioritize this issue in 2019. 

    4. Surprise! Here is a medical bill you didn’t expect

    Medical practices can expect to see a push to curb surprise medical bills, including efforts to empower patients and consumers through improved access to healthcare cost information. The sticker shock of surprise hospital bills continues to make headlines and draw bipartisan attention in Congress, making this issue ripe for legislative action in 2019.

    5. A spoonful of new regulations to help drug prices go down

    With a new Congress and support from the Administration, reducing Medicare drug prices is on the action list for 2019. For physician-administered drugs, one proposal seeks to curb the price of drugs in Part B by tying prices to a new International Price Index, create new private-sector vendors to supply practices with drugs, and set drug administration cost as a flat fee. CMS is also looking to give Part D drug plans greater flexibility to negotiate drug prices in protected classes. 

    6. The stakes are higher in MIPS

    Implementation of the Merit-based Incentive Payment System (MIPS) continues to ramp up. In 2019, MIPS performance will determine whether clinicians receive a positive or negative payment adjustment of up to 7% on 2021 Medicare reimbursement. Medicare is accelerating cost accountability for MIPS clinicians by increasing the cost component to 15% of the overall MIPS score and introducing episode-based measures. The performance threshold required to avoid a payment penalty also doubles from 15 to 30 points in 2019. With more on the line this year, it is critical that MGMA members prepare their practices for success. Visit for helpful resources. 

    7. Data interoperability a priority for feds

    The Office of the National Coordinator for Health Information Technology (ONC) is expected to release regulations to meet requirements of the 21st Century Cures Act and facilitate improved data sharing between healthcare entities. ONC will define and seek to discourage “information blocking,” develop a framework to facilitate data movement between heath information exchange entities, and release specifications for the use of apps to foster data exchange between different providers and between providers and patients. The goal of using apps, a component of MIPS and Stage 3 Meaningful Use, is to permit practices to efficiently and securely move administrative and clinical data via their EHR.    

    8. Cybersecurity continues to be a top practice concern

    Medical practices can be a prime target for phishing and other cybersecurity attacks because they possess valuable information assets (patient clinical and financial data) and often have inadequate cybersecurity protections. HHS’ HIPAA enforcement arm is expected to ramp up audits and fines in 2019. Medical practices should protect both their data and business continuity by completing a comprehensive risk assessment, identifying vulnerable areas of the organization, and taking the steps necessary to mitigate risk. Check out MGMA security resourcesto prepare your practice this year. 

    9. Site-of-service payment differentials remain a target

    Policymakers will continue the trend toward site-neutral payments with the goal of equalizing Medicare payments for the same services across clinical sites. Medicare expanded this policy through 2018 rulemaking by phasing-in payment reductions for clinic visits at hospital outpatient departments (HOPDs), including HOPDs expected from previous site-neutral payment rules. In addition to saving money for patients and the government, site-neutral payments are viewed as a policy lever for increasing market competition, eliminating the incentive for hospitals to purchase freestanding clinics and leveling the playing field. 

     10. “Repeal and replace” is out, “Medicare for all” is in 

    This shift in power within Congress will recast the role the federal government plays in healthcare in 2019. With “Medicare for all” a key platform for many progressives during the 2018 primaries, the politicized debate over a single-payer health system shows no signs of slowing down and will likely gain steam ahead of 2020 elections.

    Passage of any major health reform bill is highly unlikely anytime soon. However, as presidential contenders begin campaigning for the 2020 primaries, universal healthcare will almost certainly become a point of debate.

  • 11/17/2017 12:38 PM | Anonymous


    See below update from Elizabeth Woodcock regarding Medicare Final Rule. Join us for a
    webinar December 12 at 11:00am to hear more from Elizabeth.

    2018 Medicare Reimbursement: Final Rule

    Just hours within the release of the Final Rule concerning the 2018 revisions to the Quality Payment Program (QPP) on November 2, the Centers for Medicare & Medicaid Services (CMS) published the ruling that governs the Medicare Physician Fee Schedule (PFS) for the coming year. Although overshadowed by the QPP announcement on the same day, the Medicare PFS Final Rule’s impact on physician reimbursement is arguably the more far-reaching of the two announcements. Let’s break down the highlights of CMS’ ruling.

    First, the Medicare Access to Care and CHIP Reauthorization Act (MACRA) promised a 0.50% bump in reimbursement. While CMS granted that increase, its efforts to remain under a Congressionally-imposed target for the recapture of misvalued service codes, as well as to offset spending for new services, effectively whittled away a good portion of that amount. In the end, the PFS conversion factor for 2018 is $35.99, compared to 2017’s $35.89.

    Impacts on Specialties 

    As usual, there are winners and losers. Based on CMS’ assessment of reimbursement changes included in the Final Rule, Allergy, Anesthesiology, Pathology, Urology, Otolaryngology, Oral/Maxillofacial Surgery, and Vascular Surgery will experience declines of 1% to 3%, while Cardiology, Dermatology, Infectious Disease, Radiation Oncology, Rheumatology, Podiatry, Psychiatry, and Plastic Surgery are projected to gain. The boost in reimbursement for these physician specialties, however, is projected to be only 1%.

    Related to individual services, Primary Care performing behavioral health is a victor, with a payment increase resulting from an assessment of related office expenses. The set of care management codes introduced in 2017 – such as G0502 – migrate to permanent status by requiring the use of a CPT code. Primary Care Practitioners will also benefit from new prolonged services codes, G0513 and G0514. These new codes should be used when a clinician provides a prolonged (30-plus minutes) Medicare-covered preventive service.

    Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) will reap the benefit of new codes for chronic care management, behavioral health, and psychiatric collaborative care, created exclusively for their use. The payment will be in addition to the standard RHC/FQHC visit rate, a huge opportunity for these so-designated community health centers.

    The Medicare Diabetes Prevention Program (MDPP) expanded model moves into permanent payment status as of 2018. Anesthesiologists will use new codes for anesthesia services “furnished in conjunction with and in support of gastrointestinal endoscopic procedures,” which CMS values in the Final Rule. Emergency Medicine will reap the benefits of a similar assessment of its codes (99281-99385), but not until 2019.

    VBPM Penalties Modified

    Perhaps the biggest beneficiaries of the PFS Final Rule, however, are the physicians who were slated to be penalized via the Value-based Payment Modifier program. Except for those who had opted out of Medicare, all US-based health care professionals “participated” in the VBPM program, which piggy-backed on the Physician Quality Reporting System (PQRS). For those who did not report for PQRS, penalties for practices of 10 or more eligible clinicians were scheduled to be 4%, with smaller practices faced with a 2% reduction. In the Final Rule, these automatic downward adjustments — that were being imposed in addition to the PQRS penalty of 2% — were changed to 2% and 1%, respectively. Even if the program determined you were “high” cost or “low” quality, all clinicians participating in reporting are being held harmless in 2018. In addition to reducing the penalties, the negative information won’t be reported to the public via Physician Compare. On the flip side, the maximum upward adjustments for high-quality, low-cost physicians were sliced to half of what CMS originally proposed.

    Off-Campus Hospital Practices

    Hospitals operating off-campus clinics get some especially dismal news in the Final Rule: a 20% decrease in reimbursement. Expect more cuts next year, as CMS espouses: “[W]e continue to believe the payment policy … should ultimately equalize payment rates between nonexcepted off-campus PBDs [provider-based departments] and physician offices to the greatest extent possible….” This decrease affects off-campus PBDs billing under the relatively new place of service (POS) code 19. Private practices have welcomed this policy change, as rates have been much higher in hospital-based clinics. This payment variance, according to many industry observers, is a key reason that hospitals have purchased physician practices. With this effort to ensure rate parity, the volume of acquisitions could possibly decline. This 20% decrease will not impact on-campus clinics, billed under POS 22.

    Telehealth and Mobile Health

    For nearly a decade, CMS has added CPT codes to the list of services that are covered for Medicare when provided via telehealth. This year is no different with the following codes now being reimbursed:

    G0296 (Visit to determine low-dose computed tomography eligibility);
    90785 (Interactive Complexity);
    96160 and 96161 (Health Risk Assessment);
    G0506 (Care Planning for Chronic Care Management); and
    90839 and 90840 (Psychotherapy for Crisis).

    Furthermore, CMS is eliminating the need to use the GT modifier for telehealth services, which was considered a duplicate effort as a result of the designated telehealth POS code, 02. This special POS code, which was introduced in 2017, will still be required.

    Mobile health gets a huge boost from this Final Rule with CMS pledging to pay separately for CPT 99091.* Historically considered bundled, this code, which incorporates “remote patient monitoring,” is now valued at 1.1 work relative value units. CMS’ policies for its use are: (1) the patient must be informed in writing, and the consent be documented in the patient’s record; (2) a face-to-face service must be provided to the patient within the previous year, at which time the remote monitoring is initiated; and (3) the service can only be billed once in a 30-day period.

    Additional Impacts

    Still unknown is the Final Rule’s impact on Oncology, Rheumatology and other specialties using biologics because CMS says it intends “to provide for the separate coding and payment for products approved under each individual abbreviated application, rather than grouping all biosimilars with a common reference product into codes.”

    Those who provide advanced imaging services learn in the Final Rule that the Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging will begin with “educational and operations testing” in 2020. CMS provides a 24-month period for physicians to focus on the Quality Payment Program (QPP) until the AUC Program is launched.

    CMS also provides a peak into comments based on its request to assess the evaluation and management (E/M) coding guidelines by referring to the differences between the 1995 and 1997 guidelines, as well as the impact of electronic health records, as among the several challenges that providers confront in appropriately using the set of codes. CMS will continue to accept comments; however, the agency also announced: “We are immediately focused on revision of the current E/M guidelines in order to reduce unnecessary administrative burden.” This statement indicates future changes, which will affect the vast majority of physicians and advanced practice providers.

    All in all, 2018 will be another tumultuous year, yet this fact should come as no surprise in an ever-changing and challenging reimbursement environment.

    *99091 is the collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.

    Elizabeth Woodcock, MBA, CPC, FACMPE 


  • 06/07/2017 8:41 AM | Anonymous

    One of the nation’s largest vendors of electronic health records software, eClinicalWorks (ECW), and certain of its employees will pay a total of $155 million to resolve a False Claims Act lawsuit alleging that ECW misrepresented the capabilities of its software, the Justice Department announced. The settlement also resolves allegations that ECW paid kickbacks to certain customers in exchange for promoting its product. ECW is headquartered in Westborough, Massachusetts. 

    “Every day, millions of Americans rely on the accuracy of their electronic health records to record and transmit their vital health information,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division. “This resolution is a testament to our deep commitment to public health and our determination to hold accountable those whose conduct results in improper payments by the federal government.” 

    The American Recovery and Reinvestment Act of 2009 established the Electronic Health Records (EHR) Incentive Program to encourage healthcare providers to adopt and demonstrate their “meaningful use” of EHR technology. Under the program, the U.S. Department of Health and Human Services (HHS) offers incentive payments to healthcare providers that adopt certified EHR technology and meet certain requirements relating to their use of the technology. To obtain certification for their product, companies that develop and market EHR software must attest that their product satisfies applicable HHS-adopted criteria and pass testing by an accredited independent certifying entity approved by HHS. 

    In its complaint-in-intervention, the government contends that ECW falsely obtained that certification for its EHR software when it concealed from its certifying entity that its software did not comply with the requirements for certification. For example, in order to pass certification testing without meeting the certification criteria for standardized drug codes, the company modified its software by “hardcoding” only the drug codes required for testing. In other words, rather than programming the capability to retrieve any drug code from a complete database, ECW simply typed the 16 codes necessary for certification testing directly into its software. ECW’s software also did not accurately record user actions in an audit log and in certain situations did not reliably record diagnostic imaging orders or perform drug interaction checks. In addition, ECW’s software failed to satisfy data portability requirements intended to permit healthcare providers to transfer patient data from ECW’s software to the software of other vendors. As a result of these and other deficiencies in its software, ECW caused the submission of false claims for federal incentive payments based on the use of ECW’s software. 

    “This settlement is the largest False Claims Act recovery in the District of Vermont and we believe the largest financial recovery in the history of the State of Vermont,” said Acting U.S. Attorney Eugenia A.P. Cowles for the District of Vermont. “This significant recovery is a testament to the hard work and dedication of this office and our partners in the Commercial Litigation Branch of the Civil Division and at HHS. This resolution demonstrates that EHR companies will not succeed in flouting the certification requirements.” 

    Under the terms of the settlement agreements, ECW and three of its founders (Chief Executive Officer Girish Navani, Chief Medical Officer Rajesh Dharampuriya, M.D., and Chief Operating Officer Mahesh Navani) are jointly and severally liable for the payment of $154.92 million to the United States. Separately, Developer Jagan Vaithilingam will pay $50,000, and Project Managers Bryan Sequeira, and Robert Lynes will each pay $15,000. 

    As part of the settlement, ECW entered into a Corporate Integrity Agreement (CIA) with the HHS Office of Inspector General (HHS-OIG) covering the company’s EHR software. This innovative five-year CIA requires, among other things, that ECW retain an Independent Software Quality Oversight Organization to assess ECW’s software quality control systems and provide written semi-annual reports to OIG and ECW documenting its reviews and recommendations. ECW must provide prompt notice to its customers of any safety related issues and maintain on its customer portal a comprehensive list of such issues and any steps users should take to mitigate potential patient safety risks. The CIA also requires ECW to allow customers to obtain updated versions of their software free of charge and to give customers the option to have ECW transfer their data to another EHR software provider without penalties or service charges. ECW must also retain an Independent Review Organization to review ECW’s arrangements with health care providers to ensure compliance with the Anti-Kickback Statute. 

    “Electronic health records have the potential to improve the care provided to Medicare and Medicaid beneficiaries, but only if the information is accurate and accessible,” said Special Agent in Charge Phillip Coyne of HHS-OIG. “Those who engage in fraud that undermines the goals of EHR or puts patients at risk can expect a thorough investigation and strong remedial measures such as those in the novel and innovative Corporate Integrity Agreement in this case.” 

    The settlement with ECW resolves allegations in a lawsuit filed in the District of Vermont by Brendan Delaney, a software technician formerly employed by the New York City Division of Health Care Access and Improvement. The lawsuit was filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private individuals to sue on behalf of the government for false claims and to share in any recovery. The Act also allows the government to intervene and take over the action, as it did in this case. As part of today’s resolution, Mr. Delaney will receive approximately $30 million. 

    This matter was jointly handled by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office for the District of Vermont, the HHS Office of Inspector General, and multiple HHS agencies and components.

    -This article originally posted by The United States Department of Justice, Office of Public Affairs on May 31, 2017


  • 05/05/2017 11:52 AM | Anonymous

    Today (May 4), the House of Representatives passed an amended version of the American Health Care Act (AHCA), H.R. 1628, by a vote of 217-213. This version of AHCA has not yet received a score from the Congressional Budget Office (CBO). In the previous version, CBO estimated that under the AHCA 14 million fewer people would have health insurance coverage in 2018 and 24 million fewer by 2026. Among other changes, this legislation would: 

    • Repeal the Affordable Care Act tax credits and replace them with advanceable, refundable flat tax credits adjusted for age  
    • Impose a 30% late enrollment penalty on premiums for individuals who have lapsed in consecutive coverage for 63 consecutive days or longer
    • Modify the age-rating limit, which would allow insurers to significantly raise premiums for older adults
    • Fund separate state high-risk pools for more expensive patients, which is intended to lower premiums
    • Incentivize the use and expansion of health savings accounts
    • Allow states to apply for waivers that would: 
      • Redefine required coverage for mandated essential health benefits, 
      • Further increase the age rating ratio, or 
      • Eliminate the ban against significant increases in premiums for people with pre-existing conditions; 
    • Repeal the Medicaid expansion program and phase out current enhanced federal matching rates, with certain exceptions
    • Permit states to institute a Medicaid work requirement
    • Allow states to choose between a Medicaid per capita allotment or flexible block grant federal financing structure

    The legislation will now be sent to the Senate where it will be subject to debate. All Democratic and many Republican Senators have expressed significant reservations. If the Senate decides to advance the legislation, it is almost certain to be amended, which would require another House vote prior to final passage.   

    -This article originally published in the May 4th MGMA Washington Connection
  • 04/17/2017 11:22 AM | Anonymous


    Let’s Start from the Top: CMS Quality Payment Program

    If you are trying to figure how your practice fits into the next round of healthcare reform, look no further than this article. I am excited that CMGMA is part of the Colorado Quality Payment Program Coalition (COQPP).The mission of the COQPP is to raise awareness of the payment program amongst Colorado providers, organize education efforts, and create effective assistance for physician practices.

    There are many organizations participating in this effort to eliminate silos across the delivery of care in Colorado.

    To gain a better understanding of the program, the CMS has created a website to explain how you can participate. The program is essentially the two tracks of MIPs and Advanced APMs.  The goals of these programs are to provide high-quality patient-centered care, continuous improvement, and useful feedback from all stakeholders. Providers are eligible for MIPs if they have more than $30,000 in billings AND see more than 100 Medicare beneficiaries per year. If you participate in an Advanced APM, you are excluded from MIPs. Click Here to download an executive summary of QPP.

    The COQPP is here to assist you in receiving resources and technical support as you continue to adapt to the ever-changing delivery model. The website includes educational material on how to find help in Colorado, and which representative is designated to serve your practice. There are many resources available once you determine the path you want to take, so please take advantage of the quality improvement consultants and grant monies available.

    One of the organizations dedicated to providing resources in Colorado is TMF Health Quality Institute. They are tasked with proving consultants and technical assistance for group practices with less than 16 physicians. A couple weeks ago, Elaine Gillaspie presented to the COQPP  . Her presentation outlined the network of companies supporting QPP. TMF is happy to assist CMGMA and your practice as you gear up for your place at the table. This table is a resource illustrating the networks of resources that are available.

    If you do not meet the criteria to participate in TMF’s offerings, check out the COQPP website as we will be updating it with more information as the network develops. CMGMA will also be providing more education opportunities to highlight the other components that comprise QPP. The moral of the story is that you are not alone; you just need to know where to look. I hope this article shed some light in meeting the mission of your practice.


    Eric W. Speer, President CMGMA


  • 01/17/2017 12:23 PM | Anonymous

    Top Ten Health Policy Issues to Watch in 2017

    As a new Administration and Congress come into power, MGMA Government Affairs has identified the following legislative and regulatory issues as top priorities for medical group practices in the coming year. MGMA will keep members apprised of key developments in these areas, and will be calling on the Trump Administration and Congress to work in a bipartisan manner to pursue legislative and regulatory changes that will enable practices to thrive in their mission to furnish high-quality, cost-effective patient care. Members are encouraged to maximize their Association benefits, which include expert guidance from government affairs staff on federal legislative and regulatory requirements. Email or call 877.275.6462 with your questions. We also regularly add new information and resources to the government affairs webpage and as always, stay tuned to the Washington Connection for weekly and breaking news updates. 

    1. New Congress tackles repeal and replacement of the Affordable Care Act 

    When President-Elect Trump is inaugurated on Jan. 20, Republicans will control both the legislative and executive branches of the federal government for the first time in more than ten years. The two branches are expected to address deregulation, tax cuts, entitlement programs and repeal and replacement of the Affordable Care Act (ACA). Last week, Congress took the first step by introducing a budget resolution instructing key congressional committees to develop ACA repeal legislation, but this resolution is a statement of priorities and does not have the force of law. Practical implications for medical group practices will remain unclear until a specific replacement plan emerges. MGMA is closely tracking this issue and will engage Congress to ensure any resulting legislation supports policies that reduce the excessive administrative burden faced by practices in our healthcare system today. 

    2. Trump Administration priorities include reducing government's role in healthcare

    President-Elect Trump’s pick for the top position at the Department of Health and Human Services (HHS), Rep. Tom Price, MD (R-GA), is no newcomer to the field. If confirmed, he would be the first physician Secretary of HHS since the first Bush Administration. Price has been a frequent and outspoken critic of government involvement in the patient-physician relationship and a vocal opponent of the ACA since its inception, authoring several legislative alternatives to the Act. Trump has also nominated Seema Verma, the president of a national health policy consulting practice, to head the Centers for Medicare & Medicaid Services (CMS). 

    Trump has indicated price transparency and reducing drug costs will be a priority for his incoming Administration. What remains unclear are the details for how Trump will implement these policy priorities and how these would intersect with his and Price’s goal to provide regulatory relief and reduce the federal government’s influence in how healthcare services are delivered and paid. 

    3. Physician practices test the waters in MIPS

    A sweeping new quality reporting and value-based payment initiative stemming from the Medicare Access and CHIP Reauthorization Act (MACRA), known as the Medicare Quality Payment Program (QPP), took effect on Jan. 1. In 2017, most physician practices will participate in the new quality reporting track of the QPP known as the Merit-Based Incentive Payment System (MIPS), which replaces PQRS, the Value-Based Payment Modifier, and Meaningful Use and potentially adjusts payment of Medicare Part B claims accordingly. In this first year of MIPS, physician performance will be compared in three categories: quality, advancing care information and practice improvement activities. Following MGMA’s concerted advocacy efforts, CMS established a flexible transition-year policy allowing group practices to potentially receive an incentive payment for reporting data for any 90 consecutive day period in 2017, or avoid a penalty by reporting a small amount of data, such as one quality measure for one patient. MGMA recommends group practices report more than the absolute minimum required data as added insurance against a penalty in the event of data submission issues or inaccuracies. Access resources to help your group succeed in MIPS at MGMA’s MACRA/QPP Resource Center.

    4. Will alternative payment models (APMs) flourish under the new Administration?

    In late December, CMS unveiled a flurry of new Advanced APMs, which by the agency’s calculations are expected to increase the overall number of clinicians participating in an Advanced APM from 70,000 to 200,000 by 2018. CMS has notably placed an emphasis on developing specialty-focused Advanced APMs, which now feature a number of cardiac, orthopedic, oncology, and nephrology-focused models. With MACRA passing with broad, bipartisan support in Congress, its enduring legacy featuring APMs as a focal point is expected to continue. The incoming Congress and Administration, however, have been heavily critical of mandatory demonstration projects and have repeatedly chastised the CMS Innovation Center, the entity charged with developing APMs. These factors raise a question about whether the APM infrastructure sculpted largely by the Obama Administration will proceed in its current form or a new system under the Trump Administration. MGMA will continue to be vigilant in advocating for group practice-friendly APM options.

    5. Focus on improving health information technology (HIT) usability, interoperability

    One notable shortcoming of the Meaningful Use program was its lack of focus on EHR usability and effective and secure data sharing. 2017 will see implementation of legislation enacted late last year that could impact group practice adoption and use of HIT by reducing regulatory or administrative burdens relating to the use of EHRs (such as documentation requirements); prioritizing EHR usability and user-centered design, encouraging voluntary certification of EHRs for medical specialties (specifically pediatrics), requiring the development of a “trusted exchange framework,” and penalizing information “blocking” with fines of up to one million dollars. 

    6. Expanded payment for care management

    CMS continues its trend of expanding Medicare payments for care management services by including in the 2017 physician fee schedule (PFS) complex chronic care management (CCM), care plan development, and non-face-to-face prolonged evaluation & management services. Additionally, in response to concerns raised by MGMA and other stakeholders, CMS mitigated the onerous billing requirements for CCM. For instance, beginning in 2017, CMS is limiting the face-to-face initiating visit requirement to CCM patients who are new or who have not been seen within the past year, rather than all beneficiaries receiving CCM services. For more information about the improvements to CCM and new billable services, read MGMA’s member-exclusive analysis of the 2017 PFS final rule.

    7. New efforts promote revenue cycle automation

    Despite the inclusion of numerous administrative simplification provisions in HIPAA and the ACA, industry adoption of automated administrative transactions is less than optimal. In 2017, both the public and private sectors are expected to move forward with new standards and initiatives aimed at increasing the use of electronic administrative transactions. It is anticipated that CMS will publish a long-awaited regulation establishing a standard for electronic attachments that could greatly simplify the process of supporting claim submission or other requests from health plans for patient medical records in addition to other expected regulations and guidance. Further, MGMA and other provider organizations are actively engaging the government, commercial health plans, vendors and others to join in working to reduce the burdens associated with revenue cycle tasks such as prior authorization, establishing patient insurance eligibility, and receiving payment for medical services.

    8. Forecast unclear: Will health plan mergers continue under new Administration?

    Mergers, acquisitions and consolidation among healthcare insurers have been on the rise, but the direction of these types of partnerships remains uncertain under a Trump Administration. The Department of Justice (DOJ) and Federal Trade Commission (FTC) continue to police these consolidations, most notably with the DOJ moving to block mergers between four of the five largest health insurance plans—Aetna’s acquisition of Humana and Anthem’s acquisition of Cigna. Complaints filed by the DOJ in July alleged the unions would restrict competition and potentially harm American consumers by increasing prices and reducing benefits. Decisions in both matters are imminent. While antitrust issues are somewhat insulated from political shifts, President-Elect Trump’s philosophy on anti-competition policy is largely unknown. Policy shakeups, such as ACA repeal, may also play a role in the race toward consolidation and whether the demise of the federal exchanges could lead to a significant shift in market power.

    9. Unprecedented amount of Medicare quality and financial data slated to go public

    In recent years, Medicare has been steadily increasing the amount of clinician data it discloses to the public related to performance on quality metrics and financial relationships with drug and device manufacturers through the Physician Compare and Open Payments websites. Provided the incoming Administration proceeds with these ongoing transparency initiatives, 2016 Open Payments data is scheduled to be released in mid-2017 and 2016 PQRS data is expected to be posted to the Physician Compare site in late 2017. For the first time, CMS will publish PQRS data submitted by individual clinicians, as well as PQRS data reported by group practices and ACOs. MGMA has raised concerns over the potential adverse consequences of publishing data that has a reputation for being outdated, inaccurate and subject to misinterpretation and will continue to work with the new Administration to ensure that any data reported is accurate and easily interpretable for consumers.

    10. Patient data security at risk now more than ever—practices vulnerable to breaches, audits

    The healthcare environment has witnessed a marked increase in the number of data breaches, both accidental and by unauthorized individuals. As more patient data is being stored and transmitted electronically, physician practices are increasingly vulnerable to internal and external security threats. Several federal agencies, including CMS, the Office for Civil Rights, and the Office of the Inspector General, are more actively enforcing HIPAA privacy and security regulations. Conducting a comprehensive risk analysis and review of your organization’s policies and procedures is your best defense against experiencing a data breach or failing a government audit, and is required under MIPS. Access MGMA’s HIPAA Resource Center for tools and guidance.

    -This article originally published in the January 11 edition of MGMA Washington Connection

  • 12/07/2016 9:43 AM | Anonymous

    Today the Senate joined the House of Representatives in passing the 21st Century Cures Act, a $6.3 billion package of medical innovation bills that includes $4.8 billion to the National Institutes of Health as well as $1 billion in state grants to fight opioid abuse. The legislation contains a number health IT-related provisions including reducing administrative and regulatory burdens related to the use of EHRs, improving the EHR certification process by focusing on product security and user-centered design, the ability to share patient data, and ensuring that real world testing of the software has been conducted. The Act also calls for the creation of a voluntary EHR certification program for medical specialties for which no certified technology currently exists (i.e., pediatrics). Improving interoperability is also emphasized in the Act, with a mandate to develop and support a trusted framework for exchange of health information between networks, conduct a study on patient matching, and take steps to fight health information “blocking.” President Obama is expected to sign the legislation.

    -This article originally posted in the December 7 edition of the MGMA Washington Connection

  • 11/18/2016 12:26 AM | Anonymous

    Medicare Part B’s monthly premiums for one-third of Medicare beneficiaries will increase about 10% in 2017 to $134 from $121.80 in 2016. About 70% of beneficiaries will be “held harmless” from the increase due to a lower than usual Social Security cost-of-living adjustment. For beneficiaries held harmless, the average 2017 premium will be about $109, up from $104.90. The annual deductible for all Medicare Part B beneficiaries will be $183 in 2017, compared to $166 in 2016. Read the CMS announcement.

    -This announcement originally posted in the 11/16/2016 MGMA Washington Connection

  • 08/01/2016 5:37 AM | Anonymous

    Our new website is now live and available for use! We hope you enjoy the new look and new functionality. This new membership website will make it easier to join and renew online and will make our events (and event payments) much easier for everyone. Let us know if you have any comments or suggestions on how we can make this site work better for you.


To provide educational opportunities and resources to promote professionalism in medical practice management.


We  improve  the  delivery  and  management  of  healthcare  by  assisting  our  members’  success  through education,  networking  and  advocacy.


Colorado MGMA
P.O. Box 380084
Birmingham, AL 35238-0084
(985) 290-8020