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Tuesday, July 19, 2016

CMS to calculate new payment rates for lab tests

If your practice has an office laboratory, a new final rule issued by the Centers for Medicare & Medicaid Services (CMS) may affect you.

The rule requires that certain clinical labs report how much they receive from private insurers for lab tests as well as lab test volumes. CMS plans to use this information to calculate new Medicare payment rates under the Clinical Laboratory Fee Schedule (CLFS), beginning in 2018.

Only labs that receive at least $12,500 a year in Medicare revenues from laboratory services paid under the CLFS and more than half of their Medicare revenues from laboratory and/or physician services will have to report.

CMS estimates this will include only 5 percent of physician office labs and about half of independent labs. However, the information provided by those labs will help revise Medicare payment rates for everyone.

Under the plan, the affected labs will collect payer data from the first six months of this year and report it to CMS between Jan. 1 and March 31 of next year. CMS will then calculate the new Medicare rates, based on a weighted median of private payers for each test, and post them in early November 2017. They will go into effect Jan. 1, 2018.

For more information, see the CMS press release and detailed fact sheet.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, July 14, 2016

CMS looks to reduce 2016 meaningful use reporting period to 90 days

The Centers for Medicare & Medicaid Services (CMS) has proposed reducing the amount of time physicians and practices need to report to comply with the meaningful use (MU) program.

Originally, eligible professionals and eligible hospitals needed to report a full year’s worth of data from their electronic health records (EHRs) to meet the 2016 requirement and avoid a financial penalty.

But as part of a group of proposed policy and payment changes released earlier this month and published in the Federal Register this week, CMS says it would require those parties to submit data for any continuous 90 days between Jan. 1 and Dec. 31 of this year.

“We believe it would continue to assist health care providers by increasing flexibility in the program,” CMS said in a release, noting this is the same reporting period as in 2015.

CMS also said that physicians and hospitals who have not successfully attested to MU in a previous year would have to meet modified Stage 2 requirements by Oct. 1, 2017, instead of Stage 3.

Also, certain eligible professionals who have not successfully demonstrated MU in a previous year, plan to attest to MU in 2017, and plan to report data for the advancing care information performance category under the Merit-Based Incentive Payment System (MIPS) in 2017 can apply for a significant hardship exception from payment penalties in 2018.

CMS is accepting comments on the proposed rule though Sept. 6 before releasing a final rule.

If you don’t want to read the full proposed rule, CMS released a more succinct fact sheet

Monday, July 11, 2016

CMS releases proposed rule on 2017 Medicare physician fee schedule

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule on the 2017 Medicare physician fee schedule. Primary care physicians should be interested that the rule includes several proposed increases for care management services. Specifically, CMS is proposing to pay for:

•    Non-face-to-face prolonged evaluation and management services
•    Comprehensive assessment and care planning for patients with cognitive impairment
•    Primary care practices to use interprofessional care management resources to treat behavioral health conditions
•    Resource costs of furnishing visits to patients with mobility-related impairments
•    Chronic care management (CCM) for patients with more complex conditions

In addition, CMS proposes to reduce the administrative burden associated with the CCM codes to encourage more practices to furnish and bill for these services. CMS also will revalue existing codes describing face-to-face prolonged services.

For 2017, CMS estimates the conversion factor to be $35.7751, which is slightly lower than the 2016 conversion factor of $35.8043. However, CMS expects that the provisions of the proposed rule will generate an estimated 3 percent increase in Medicare allowed charges for family physicians. That would be the largest estimated update for a given specialty.

For individuals who don’t want to read the proposed rule itself, CMS has provided an abbreviated fact sheet and press release. CMS is accepting comments on its proposals through Sept. 6.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, July 7, 2016

JW modifier allows physicians to get paid for some discarded drugs

The Centers for Medicare & Medicaid Services (CMS) recently revised its guidance on how to use the JW modifier. Specifically, the revision will make it easier for physicians to get paid for leftover medication or biologicals that are properly thrown out.

Beginning Jan. 1 of next year, physicians must use the JW modifier for claims with unused drugs or biologicals from single-use vials or single-use packages that are appropriately discarded (except those provided under the Competitive Acquisition Program for Part B drugs and biologicals). The physician must also document the discarded drug or biological in the patient's medical record when submitting Part B claims.

For example, imagine you administer 95 units of a drug from a single-use vial that is labeled to contain 100 units and discard the remaining five units. You bill the 95-unit dose on one line of the claim and bill the discarded five units on another line by using the JW modifier. Both line items would be processed for payment. You apply the JW modifier only to the amount of drug or biological that is discarded.

You may not use the JW modifier when the billing unit is equal to or greater than the total actual dose and the amount discarded. For example, if one billing unit for a drug is 10 mg in a single-use vial and you administer 7 mg and discard the remaining 3 mg, you can bill the 7 mg dose as one 10 mg unit. You could not also bill the discarded 3 mg on a separate line item with the JW modifier because that would result in overpayment.

Medicare administrative contractors currently have discretion over whether to require the JW modifier for any claims with discarded drugs or biologicals, and how the discarded drug or biological information should be documented. CMS is revising this policy to create more uniformity for these types of claims.

For additional information on billing Medicare for discarded drugs and biologicals, see section 40 of chapter 17 of the Medicare Claims Processing Manual.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, June 28, 2016

CMS places some limits on review of Medicare claim denials

If you’ve ever appealed a Medicare claim denial only to see it struck down for new reasons that the reviewers found in the course of their review, help may be coming.

The Centers for Medicare & Medicaid Services (CMS) recently told its Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) to change how they review certain claim denials. Specifically, CMS says they should limit their review of redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review to the reason or reasons the claim or line item was denied in the first place.  

CMS acknowledged that MACs and QICs generally have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to the claim or line item. As a result, while the original reason for the denial may be resolved, this expanded review may result in a denial of the appeal for new reasons. The revised instructions prohibit the contractors from doing that in certain situations, which is good news for physicians and others who initiate such appeals.

However, MACs and QICs will still have the discretion to develop new issues and evidence for claims denied as a result of automated pre-payment review. MACs will also continue to follow existing procedures for adjusting claims after successful appeals, meaning CMS will process the adjustments and may suspend them because of system edits. Claim adjustments that remain unpaid because of additional system-imposed limitations (e.g., frequency limits or Correct Coding Initiative edits) may result in new denials with full appeal rights.

In addition, if a MAC or QIC conducts an appeal of a claim or line item that was denied on pre- or post-payment review because of insufficient documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, which means the claim could subsequently be denied for lacking medical necessity. If you receive requests for additional documentation, please be careful to respond quickly and completely to prevent the possibility of expanded review of the whole claim.

Finally, CMS is applying the new guidance only to appeals received by a MAC or QIC on April 18 or later. Prior denials based on expanded evidence will not be reopened.

As noted, the CMS guidance provides some good news to physicians and other providers of Medicare services. But CMS has placed a number of limits on this guidance, and you will need to be aware of the phase and type of review (e.g., pre- or post-payment, automated or complex) to which a claim is subject and consider the possibility of subsequent system edits and denials when determining whether to appeal.   

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, June 24, 2016

Make sure to recertify EIDM users by June 30

Time is running out if your practice hasn’t recertified its user accounts in the Enterprise Identity Management (EIDM) system. Letting those accounts lapse could complicate reviewing your Quality and Resource Use Reports (QRURs) later.

Individual practitioners and providers’ security officials (SOs) have until June 30 to log into the system and recertify who in the practice has the right to access the system. The Centers for Medicare & Medicaid Services (CMS) requires users to recertify annually. Failure to recertify user roles will result in those roles being revoked. Once revoked, the user must go through the process of requesting the role from the SO or individual practitioner again.

The SO and individual practitioners can log into the CMS Enterprise Portal using existing credentials and access the list of users who require recertification. The list is located under the “View and Manage Access” page under the “Annual Certification” link on the left-hand side of the screen. If you experience issues, you can contact the QualityNet Help Desk at 1-866-288-8912. The QualityNet Help Desk can also tell you who the SOs are for your Tax Identification Number (TIN).

Maintaining access to the EIDM system is critical for the QRUR. CMS releases a mid-year QRUR and an annual QRUR. The 2015 mid-year reports were released in April, while the 2015 annual reports will be available in the fall. These reports provide information on a TIN’s performance on cost and quality measures. Practices can use the QRUR to review their performance and identify areas where improvement may be needed. Reviewing today will help practices prepare for the implantation of the Medicare Access and CHIP Reauthorization Act (MACRA).

– Erin Solis is the Regulatory Compliance Strategist at the American Academy of Family Physicians

Thursday, June 23, 2016

How much can you charge patients for their health information?

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services recently addressed patients’ rights to access their protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Much of the guidance focuses on the fees that a covered entity, such as your practice, may charge patients requesting copies of their own PHI.

According to OCR, you can charge patients for:

1.    labor costs (including preparation of an explanation or summary when agreed to by the individual)
2.    supply costs related to the creation of either the electronic or paper copy (e.g., paper, toner, CD, or USB drive)
3.    postage costs when the individual requests the information be mailed

The OCR guidance indicates that permissible labor costs may include only the labor “for creating and delivering the electronic or paper copy in the form and format requested or agreed upon by the individual, once the PHI that is responsive to the request has been identified, retrieved, or collected, compiled and/or collated, and is ready to be copied.” (Emphasis added) That means you cannot charge for reviewing the request or searching for and retrieving the information.

The OCR also emphasizes that you may not charge individuals for system maintenance, data storage and maintenance, or the administrative costs associated with outsourcing your office’s response to requests for PHI. OCR further notes that if you use systems that allow individuals to access their PHI through electronic health record technology, you may not charge labor or supply costs.

The OCR guidance says that when calculating the fees you charge, they may reflect your actual costs, your average costs, or a flat fee. If using actual costs, they must be reasonable and calculated upon each request. OCR says that you can charge average costs as a standard rate (e.g., a per-page fee if you maintain the requested PHI in paper form and the individual requests a paper copy). The OCR adds that “per page fees are not permitted for paper or electronic copies of PHI maintained electronically.” Finally, you can charge a flat fee but only for electronic copies of electronically maintained PHI, and the flat fee cannot exceed $6.50.

Regardless of the fee method used, you must notify individuals in advance of any fees that could be charged for their requests for PHI at the time the details of the request are being arranged. Failure to provide such notice could potentially be a HIPAA violation.

If a patient requests that you send their PHI to a third party, you must treat that request the same under HIPAA as if the patient were requesting it be sent to them directly. However, if a third party initiates the request for PHI, the limitations on copying fees do not apply. So, you should ask whether the request was a direction from the patient or a request from a third party.

Finally, the OCR guidance discusses the relationship between HIPAA and state law. Specifically, when it comes to an individual's right to access his or her own PHI, HIPAA trumps state law if HIPAA provides individuals with greater access to their PHI. That means if your state law allows you to charge higher fees or to limit an individual’s access, HIPAA will preempt that state law.

Needless to say, now may be a good time to review your policies and procedures for granting access to individuals’ PHI, including whether and how you charge for copies of that information.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 31, 2016

CMS releases list of approved 2016 PQRS registry vendors

The Centers for Medicare & Medicaid Services (CMS) has released the 2016 lists of approved Qualified Registries and Qualified Clinical Data Registries for the Physician Quality Reporting System (PQRS). Physicians and group practices may use these third-party vendors to submit quality measures for PQRS in 2016 and potentially avoid payment penalties associated with PQRS and the Medicare value-based payment modifier in 2018.

There are a number of other PQRS reporting options. For those new to the program, the AAFP provides a PQRS overview, and CMS has instructions on how to get started.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 17, 2016

Small practices face potential headaches under MACRA

For solo and small physician practices, the recently published proposed rule for how the Centers for Medicare & Medicaid Services (CMS) plans to implement the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) set off some alarm bells. According to the proposed rule’s regulatory impact analysis, 87 percent of solo practice clinicians who are eligible for the Merit-Based Incentive Payment System (MIPS) – one of two payment tracks under MACRA – will receive a penalty; for groups of two to nine clinicians, the percentage is almost 70 percent.

Responding to the concerns generated by this analysis, CMS has now issued a fact sheet that attempts to show it is sensitive to the unique challenges that small practices face in different types of communities. The fact sheet is also meant to show that the agency’s proposed implementation of MACRA, including MIPS and alternative payment models (APMs), provides accommodations for various practice sizes and configurations. Among the provisions that CMS highlights in its defense are:

• Clinicians or groups that have $10,000 or less in Medicare charges and 100 Medicare patients or fewer are excluded from the MIPS payment adjustment.
• When a practice is scored for MIPS, it will only be scored for categories where it has a sufficient number of applicable measures and activities.
• Small groups will have more flexibility within each of the MIPS performance categories. For example, CMS will calculate only two population measures based on claims data for solo physicians and groups of nine or fewer physicians instead of the three population measures required for larger groups under the quality performance category of MIPS.

CMS also notes that the proposed rule allows small practices or practices in rural or healthcare professional shortage areas to participate in the Advanced APM track – and receive incentive payments – by providing special rules for these practices to qualify as Advanced APMs under medical home models.  

Ironically, CMS plans to delay implementing one provision of MACRA specifically intended to help solo and small group practices succeed under MIPS. Specifically, MACRA allows MIPS-eligible professionals to combine into “virtual” groups to participate in the payment track. However, as noted in the fact sheet and the proposed rule, CMS will not make this option available until the second year of the program.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, May 13, 2016

Medicare physician use and payment data for 2014 now available

The Centers for Medicare & Medicaid Services (CMS) has released its annual report on Medicare physician utilization and payment data.

Covering calendar year 2014, the public file lists Medicare Part B payments and submitted charges for more than 986,000 individual physicians and other health care providers who collectively received around $91 billion. By comparison, the report for 2013 included $90 billion in payments to 950,000 physicians and other providers.  

The latest report uses Medicare standardized payment amounts, which adjusts for geographic differences to make payments to physicians in different parts of the country comparable.

As we’ve discussed in the past, these annual payment reports show not only the range and complexity of care that family physicians provide but also the variation in reimbursement among medical specialists. For example, family physicians received an average of $61,804 in total Medicare payments during 2014. By comparison, internists received an average of $92,760 and cardiologists received an average of $222,373. As in the past, physicians weren't given an opportunity to review the information tied to their names for errors and the amounts don't reflect risk-adjustment, Medicare not covering the full cost of certain treatments, or other factors.

As CMS moves to tie physician reimbursement more closely to value, presenting accurate individual physician payment and utilization data to patients and other interested parties will become more critical.

Thursday, May 12, 2016

Some help understanding the proposed MACRA payment reforms

Last month, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that describes how CMS intends to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the Medicare sustainable growth rate methodology with a new approach that pays clinicians for the value and quality of care they provide. The proposed rule would implement these changes through a unified framework called the “Quality Payment Program,” which includes two paths – the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). Comments on the proposed rule are due to CMS by June 27.

In the regulation, CMS says it expects that most Medicare physicians will initially participate through the MIPS. The MIPS consolidates three existing programs, the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program. MIPS will pay Medicare physicians for providing high value care through success in four performance categories:

•  Quality (50 percent of total score in year one): For this category, physicians would choose to report six measures from among a range of options.
•  Advancing Care Information (25 percent of total score in year one): For this category, physicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting. CMS created a summary specific to the Advancing Care Information category.
•  Clinical Practice Improvement Activities (15 percent of total score in year one): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Physicians may select activities that match their practices’ goals from a list of more than 90 options.
•    Resource Use (10 percent of total score in year one): For this category, the score would be based on Medicare claims, meaning no reporting requirements for physicians. This category would use 40 episode-specific measures to account for differences among specialties.

CMS would begin measuring performance for physicians and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.

Under the APM pathway, MACRA authorizes incentives for physicians who take further steps towards care transformation. To qualify as an Advanced APM, an APM must 1) require participants to use certified EHR technology, 2) pay covered professional services based on quality measures comparable to those in the quality performance category under MIPS, and 3) mandate that participating APM entities bear risk for monetary losses of a more than nominal amount – or that the entity must assume risk for potential financial losses – under the APM. CMS proposes three dimensions of risk – marginal risk, minimum loss rate, and total potential risk – to determine if an entity meets the more than nominal risk standard. Medicare physicians who sufficiently participate in an Advance APM would be exempt from MIPS reporting requirements and qualify for a 5 percent Medicare Part B incentive payment.

CMS notes that physicians who participate to some extent in APMs may not meet the law’s requirements for sufficient participation in the most advanced models. But it says the proposed rule is designed to provide these clinicians with financial rewards within MIPS. CMS expects that the number of clinicians who qualify as participating in Advanced APMs will grow as the program matures.

As an alternative to reading the more than 900 pages of regulations, the CMS issued a press release and the Health and Human Services secretary published a blog post, which includes the video, “Delivery System Reform: Paying for What Works.”

Keep an eye on this space for additional information on MACRA as we more fully understand how this law will affect family physicians for years to come.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, April 21, 2016

Medicare keeping vigilant on observation services

If you or your practice provides observation care at a local hospital to Medicare patients, the Centers for Medicare & Medicaid Services (CMS) is issuing a gentle reminder to pay attention to your documentation for those services – if you don’t want to face a refund request.

In the latest issue of CMS’s Medicare Quarterly Provider Compliance Newsletter, the agency indicates it is keeping a close eye on physician billing for hospital observation services. In the article, “Comprehensive Error Rate Testing (CERT): Observation Services,” CMS notes that evaluation and management (E/M) services, such as observation services, remain a leading cause of improper Medicare payments. CMS also notes that most improper payments were due to insufficient documentation, such as:

•    No order for observation services
•    No progress notes
•    No physician’s signature on a progress note

As an example, CMS describes the case of a physician who billed Medicare for CPT 99217 (“Observation care discharge”) for a date of service in April 2013. However, the submitted documentation was missing signed and dated physician’s orders for observation services and was also missing a signed and dated progress note to support a face-to-face encounter on the date of service. The physician was unable to produce any documentation to support that he or another member of his group had seen the patient on the date of discharge from observation. Subsequently, the Medicare administrative contractor recovered the payment.

The article also reminds physicians that even when documentation is present, it must support the level of E/M observation service claimed. Failure to document the level of service claimed also constitutes a potential overpayment as far as Medicare is concerned.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, April 13, 2016

CMS provides details on Comprehensive Primary Care Plus

Like an auto company touting the latest model or a certain soda manufacturer unveiling its “new” version of an old “classic,” the Centers for Medicare & Medicaid Services (CMS) has revealed its latest effort to transform and improve how primary care is delivered and paid for in the United States. CMS will implement the Comprehensive Primary Care Plus (CPC+) model in up to 20 regions of the country, accommodating up to 5,000 practices and more than 20,000 physicians and other clinicians. It would also seek to encompass up to 25 million patients.

Building on the Comprehensive Primary Care initiative launched in late 2012, which is already being dubbed “CPC Classic,” the five-year CPC+ model will offer primary care practices two tracks for participation. Both tracks will require practices to:

•    Support patients with serious or chronic diseases to achieve their health goals
•    Give patients 24-hour access to care and health information
•    Deliver preventive care
•    Engage patients and their families in their own care
•    Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

Practices in Track 2 will also be expected to provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

Physicians participating in CPC+ will receive monthly care management fees for eligible beneficiaries in their practice. Physicians in Track 1 will be paid depending on where each patient falls across four risk tiers, with an average of $15 per beneficiary per month. In Track 2, physicians will be paid according to five risk tiers, with an average of $28 per beneficiary per month, including $100 per month for the most complex patients. Practices can use these fees for increased staffing and training necessary to meet the model’s patient care requirements.

In addition to the care management fees, Track 1 physicians will continue to receive their normal Medicare fee-for-service payments. Physicians in Track 2 will receive a new hybrid of fee-for-service payments and a “Comprehensive Primary Care Payment,” which will include a percentage of the expected Medicare reimbursement for Evaluation & Management (E/M) claims upfront. Reimbursement for the E/M claims themselves will be reduced.

In addition to these payments, CMS will award practices incentives based on performance.

Like CPC Classic, Medicare will partner under the CPC+ model with commercial and state health insurance plans. CMS will accept proposals from payers wanting to partner in CPC+ between April 15 through June 1, selecting regions of the country that reflect sufficient interest from multiple payers. Practices in the selected regions can apply to participate from July 15 through Sept. 1.

CMS is offering additional information on CPC+ through a press release, a fact sheet, and frequently asked questions.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, April 8, 2016

Open Payments review and dispute period ends May 15

Physicians and teaching hospitals have until May 15 to review financial information reported about them under the “Open Payments” system and dispute information they believe is incorrect before the information is released to the public on June 30.

The Centers for Medicare & Medicaid Services (CMS) annually asks pharmaceutical and medical device manufacturers and group purchasing organizations to report all payments or other transfers of value they made to physicians and teaching hospitals during the previous year. The June 30 release includes information for 2015, along with updates to the databases for 2013 and 2014.

The review process is voluntary, but to participate and file disputes, you will need to register in both the CMS Enterprise Identity Management System (EIDM) and the Open Payments system itself.

If you registered last year, you don’t have to register again. Go to the CMS Enterprise Portal, log in using your user ID and password, and navigate to the Open Payments system home page. If you haven’t accessed your account in the last 60 days, you will need to answer some challenge questions and then reset your password. If you haven’t visited in more than 180 days, you’ll have to contact openpayments@cms.hhs.gov to reinstate your account.

Thursday, April 7, 2016

CMS releases 2015 mid-year Quality and Resource Use Reports

The Centers for Medicare & Medicaid Services (CMS) has released the mid-year Quality and Resource Use Reports (QRURs) for 2015. These reports are released annually and serve as a tool for physicians to review their performance on a subset of measures that will be used to calculate the 2017 Value-Based Payment Modifier (VBPM).

The mid-year QRURs are for informational purposes only and cover the performance period between July 1, 2014, and June 30, 2015. This performance period differs from the actual performance period that will be used to calculate the 2017 VBPM. The reports contain data on six cost measures and three claims-based quality outcome measures.

While the performance information included on the mid-year QRUR may differ from the 2015 QRUR, which comes out in the fall, the report still offers physicians a good opportunity to review their performance and implement quality improvement activities for the upcoming year. A physician’s performance in 2016 will be used to calculate his or her 2018 VBPM.  

CMS has created resources on how to use your 2015 mid-year QRUR as well as how to obtain the report.

-- Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians

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