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Thursday, May 25, 2017

Deadline approaches to join new MACRA payment model

Next week is the deadline to notify Medicare if your practice intends to participate in a new payment model aimed at helping practices, particularly smaller ones, meet the Quality Payment Program requirements under MACRA.

The Centers for Medicare & Medicaid Services (CMS) created a new Advanced Alternative Payment Model in December called the Medicare Accountable Care Organization Track 1+. This model limits some of the downside risks that practices face in Track 2 and Track 3 under Medicare’s Shared Savings program as CMS tries to encourage more practices to participate in risk-sharing agreements.

Accountable Care Organizations (ACOs) in Track 1+ will be eligible for shared savings up to 50 percent, based on quality performance. There is a fixed 30 percent loss sharing rate. The maximum level of downside risk depends on the composition of the participating ACOs. Track 1+ is largely based on Track 1 and incorporates aspects of Track 3, such as prospective beneficiary assignment and a three-day rule waiver for skilled nursing facilities. Track 1+ qualifies as an Advanced Alternative Payment Model (AAPM) under Medicare’s Quality Payment Program beginning in 2018. Qualifying AAPM participants are eligible to receive a 5 percent bonus payment.  

Track 1+ is open to current and renewing ACO Track 1 participants as well as new participants. Those already participating in Track 2 or Track 3 cannot apply.

If your practice would like to participate in Track 1+, you must first submit to Medicare a notice of intent to apply (NOIA). The deadline for filing a NOIA is noon ET on May 31. The Centers for Medicare and Medicaid Services (CMS) has published a user guide to help physicians through the NOIA process. After submitting an NOIA, physicians must complete the Track 1+ application July 1-31. Sample 2018 applications will be made available in June.

– Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Wednesday, May 24, 2017

Medicare to require updated notice of noncoverage form

Family physicians occasionally provide services to Medicare patients for which they expect they will be denied reimbursement because they do not meet Medicare coverage rules. In those instances, they may inform their patients of the situation with a form called an Advance Beneficiary Notice of Noncoverage (ABN). The ABN allows the patient to make an informed decision about whether to still receive the service, knowing that he or she may have to pay for it out of pocket.  

In March, the federal Office of Management and Budget renewed the ABN (Form CMS-R-131) and its instructions for another three years. The new forms are largely unchanged, except for the new expiration date of March 2020 and new language informing beneficiaries of their rights under Centers for Medicare & Medicaid Services (CMS) nondiscrimination practices and how to request the ABN in an alternative format. Physicians will need to use the updated ABN form beginning June 21, although you can begin using it immediately if you wish.

CMS has published guidelines for mandatory and voluntary use of the ABN in the Medicare Claims Processing Manual, Chapter 30, Section 50. The revised form and additional information is available on the CMS Beneficiary Notices Initiative webpage.

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

Monday, May 22, 2017

How to avoid the unpaid Medicare annual wellness visit

One of the challenges of getting paid for Medicare annual wellness visits (AWVs) is that Medicare reimburses only one AWV a year per Medicare patient – and your patient may get that visit elsewhere without you knowing it. Even worse, you will not discover that fact until after you have provided the service and received a claim denial from Medicare. What’s a practice to do?

One strategy is to encourage your Medicare patients to receive their AWVs from you. A letter to your patients could emphasize that the AWV is part of the ongoing relationship between the patient and your practice, a relationship that enables you to provide them with continuity of care. It could then explain how Medicare pays for only one wellness visit per year and that you can’t provide it if they receive an AWV somewhere else.

Another strategy is to check a Medicare patients’ billing history to see if Medicare has paid for an AWV within the past 12 months. You can do this a couple of ways. One way is to contact your local Medicare administrative contractor (MAC) to verify whether enough time has passed since the patient’s last AWV for you to get reimbursed. If the patient has moved or spends part of the year in another part of the country (e.g., is a “snowbird”), you may also need to contact the MAC for the part of the country where the patient lived previously. You can identify the relevant MAC and their contact information through an interactive map from the Centers for Medicare & Medicaid Services (CMS).

Alternatively, you may want to access the CMS HIPAA Eligibility Transaction System (HETS) Help (270/271), a secure website that provides Medicare information for patient eligibility and liability. HETS is available to you for free at any time with limited functionality outside of normal business hours.

There are many frequently asked questions about the Medicare AWV. Don’t let “Am I going to get paid for this?” be one of them.

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

Wednesday, May 10, 2017

CMS provides tool to determine physicians’ MIPS participation status

The Centers for Medicare & Medicaid Services (CMS) is mailing letters alerting physicians and other health care professionals of their 2017 participation status for the Merit-based Incentive Payment System (MIPS). The agency is also offering an interactive tool on its Quality Payment Program website to determine if you should participate in 2017.

To determine your status, type your national provider identifier in the entry field of the tool. CMS will then tell you if you should participate in MIPS this year and where to find resources.

As a reminder, you are required to participate in MIPS in 2017 if you bill Medicare Part B more than $30,000 a year and see more than 100 Medicare patients a year. You must also be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse practitioner.

If you are new to Medicare in 2017, you do not have to participate in MIPS. You may also be exempt if you qualify for one of the special rules for certain types of clinicians or are participating in an Advanced Alternative Payment Model. To learn more, review the MIPS participation fact sheet.

If you are not required to participate in the program in 2017, you can still participate voluntarily. This can give you good experience for when you are required to participate,  and you will not be subject to payment adjustments.

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

Thursday, April 27, 2017

Are you participating in MIPS this year? Watch your mailbox

The Centers for Medicare & Medicaid Services (CMS) has begun mailing letters alerting physicians and other health care professionals of their 2017 participation status for the Merit-based Incentive Payment System (MIPS), one of the two reimbursement tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). Practices will receive letters from their local Medicare Administrative Contractor (MAC) through the end of May. The mailings will include three documents: a general information letter, participation information, and list of frequently asked questions.

The letters inform physicians as to whether the group and the individuals within the group are exempt from the MIPS reporting requirements based on their clinician type in 2017 or if they fall below the low-volume threshold. Eligible clinician types include: MD, DO, NP, PA, CNS, and CRNA. Clinicians are considered below the low-volume threshold if during the determination timeframe they billed less than $30,000 in Medicare allowed charges or provided care to fewer than 100 Medicare patients. CMS uses both historical claims data and data from the performance period to make this determination. The letters do not contain information on a clinician’s Advanced Alternative Payment Model (AAPM) status or hospital-based determinations.

Letters are distributed at the practice level, but will contain information on each individual associated with the tax identification number (TIN). If a practice has decided to report as a group, all clinicians within the TIN will be included in the reporting, even if a clinician falls below the threshold as an individual. Practices should review the letters and determine if they will report as individuals or as a group. Clinicians practicing in multiple TINs will need to verify their participation status with each practice.

Participation in MIPS requires clinicians and groups to report data in four performance categories in 2017 in order to avoid a negative payment adjustment in 2019.

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

Thursday, April 6, 2017

Family physician compensation stayed level in 2016

The average annual compensation for family physicians remained stable last year as a majority expressed contentment with their pay and the state of medicine.

The Medscape Physician Compensation Report 2017 shows that family physicians responding to the survey received an average of $209,000 in total compensation in 2016, up almost 1 percent from the previous year but remaining second to the last among all specialties. The average compensation for all physicians included in the survey rose more than 5 percent to $294,000, with the highest average compensation achieved once again by orthopedists at $489,000. The lowest-paid specialty was pediatrics with an average of $202,000, which represented a decrease in compensation.

When broken down by state, data showed that the three top-earning states for physicians were North Dakota ($361,000 average), Alaska ($359,000), and South Dakota ($354,000). Researchers attributed this at least partly to government efforts to bring more physicians to rural and economically disadvantaged areas.

Fifty-three percent of family physicians said they felt their compensation amount was fair, about even with the 54 percent of all survey respondents who said the same. By comparison, 52 percent of family physicians believed they were fairly compensated in 2015. Emergency medicine physicians (at 68 percent) felt the most satisfaction with their compensation in the new survey, while nephrologists (at 41 percent) were the least satisfied.

Among family physicians, 77 percent said they would choose medicine as a career if they had the choice again, in line with the overall average. But family physicians were second from the last (at 67 percent) when asked if they would choose the same specialty. Internists were last at 64 percent.

Although the survey did not disclose physician employment trends as it has in past years, it did note that self-employed physicians, on average, tend to make more than their employed colleagues ($343,000 vs. $269,000). The difference varies widely between specialties, with self-employed primary care physicians earning $223,000 and employed primary care physicians earning $214,000, a 4-percent difference.

The gender pay gap continued to shrink for primary care physicians, albeit slowly. Male physicians in primary care reported earning 16 percent more than female physicians, down from 17 percent the previous year. The gap actually widened among other specialists, where male physicians made 37 percent more then female physicians, a 4 percent increase over the previous year. Researchers said this may be because of fewer female physicians participating in some high-paying specialties.

Gender-based pay disparities are smallest at 18 percent for physicians younger than 35 years old; the pay difference is 35 percent or more for older age groups.

The pool of physicians operating in a cash-only or “concierge” practice actually diminished slightly, with 9 percent of respondents saying they belonged to those types of practices. Ten percent reported operating those types of practices in 2015.

Time ticking for MIPS registration

If your physician group intends to use the Centers for Medicare & Medicaid Services (CMS) Web Interface to report to the Merit-Based Incentive Payment System (MIPS) or the Consumer Assessment of Health Providers and Systems (CAHPS) you have until June 30 to register. You can use the Quality Payment Program (QPP) website to register. No registration is required if you are reporting as an individual or if your group is using any other reporting method.

Only groups of 25 or more clinicians can report using the CMS Web Interface. However, groups of two or more clinicians may administer CAHPS, which is optional in MIPS. Group participants in a Shared Savings Program accountable care organization do not need to register.

CMS has automatically registered groups for the CMS Web Interface if they previously registered as a group under the Physician Quality Reporting System (PQRS). If you need to review or remove your registration, you can do so through the QPP website.

To register, a member of the group must have a valid Enterprise Identity Management (EIDM) account with the Physician Value-Physician Quality Reporting System (PV-PQRS) role. If you are unsure if someone in your group has this role or need to reactivate your account, you can contact the QPP desk at 866-288-8292 or CMS has created guides for obtaining the PV-PQRS role or creating a new EIDM account. A CMS Web Interface Registration Guide, a CMS Web Interface fact sheet, and a CAHPS for MIPS fact sheet are also available. CMS will be hosting educational webinars on group reporting and registration in the future.

The QPP was created under the Medicare Access and CHIP Reauthorization Act (MACRA) and adjusts Medicare payments based on the quality of care provided by physicians instead of the volume of services. The first performance period for the QPP began on Jan. 1. More information is available on the American Academy of Family Physicians MACRA ready page.

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

Tuesday, April 4, 2017

The latest Open Payments data is ready for review

Every year, pharmaceutical and medical device manufacturers are required to given the Centers for Medicare & Medicaid Services (CMS) information about the payments or other transfers of value they make to physicians and teaching hospitals. CMS then posts this information on its Open Payments website for the public to see.

Manufacturers are currently submitting data to the Open Payments System on payments or transfers of value made during 2016. Beginning this month, physicians and teaching hospitals have until May 15 to review and dispute records attributed to them. See the Open Payments Registration webpage for more information.

CMS will hold a conference call from 1:30 p.m. to 3 p.m. on April 13 to help physicians and their staffs better understand the Open Payments program and how to review and dispute data submitted about them. CMS will publish the 2016 payment data and updates to the 2013, 2014, and 2015 data on June 30.

To register or for more information on the call, you can visit MLN Connects Event Registration or refer to the call detail page.

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

Tuesday, March 28, 2017

HHS warns of spoofing scam involving its fraud hotline

The U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) is warning that its fraud hotline telephone number is itself being used as part of a telephone spoofing scam. These scammers represent themselves as HHS OIG employees, even tricking caller ID to make it seem as if the call is coming from the HHS OIG Hotline, 1-800-HHS-TIPS (1-800-447-8477). They then try to obtain or verify the victim’s personal information, which can then be used to steal money or commit other fraud. HHS OIG is investigating and trying to shut the scam down.

In the meantime, HHS OIG stresses that it does not make outgoing phone calls using the HHS OIG Hotline telephone number, and that you should not answer calls from 1-800-447-8477. It is still safe to call into the HHS OIG Hotline to report suspected fraud and abuse. You can also use the HHS OIG Hotline to report if you believe you may have been a victim of the spoofing scam. Alternatively, you can email your information to or file a complaint with the Federal Trade Commission at 1-877-FTC-HELP (1-877-382-4357).

More information is available on the OIG Consumer Alerts webpage.

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

Tuesday, March 14, 2017

Act now to get prebooking benefits for next influenza season

The 2016-2017 influenza season is winding down, and hopefully you have used up all your influenza vaccine supply. Right?

As a former office manager, I realize that answer is probably no, and you actually have a lot of leftovers. An essential part of running a medical practice is using your electronic health record or billing system to find the correct number. Determining the amount of flu vaccines you billed over the past two or three flu seasons should help you estimate the number you should order for the 2017-2018 season. Be sure to take into account if your patient panel has grown or decreased. Not only will you be better prepared for the next season but also you can take advantage now of the prebooking options offered by various vaccine manufacturers and distributors.

Prebooking is when you turn in your vaccine order for the upcoming flu season order in advance, typically by the end of March. Admittedly, it is difficult to manage this number effectively because you are doing it an average of five to six months ahead of when you will need the vaccine in your clinic. The manufacturers and distributors have programs available that can help you manage your inventory as well as keep your costs down. Some prebooking programs have matrixes to help determine the number of vaccines to order, staggered shipping, order forgiveness, and volume discounts. These factors can lead to diminished costs, which, of course, can lead to greater profit margins.

You are encouraged to contact the major manufacturers and distributors directly to see what their individual prebooking programs offer. These will vary based on your practice size, patient panels, and volume discounts. Here is contact information for some of the manufacturers:

• Sanofi Pasteur ( 800-822-2463

• GlaxoSmithKline ( 866-475-8222

• Seqirus  ( 855-358-8966

• Protein Sciences ( 203-686-0800

– Barbie Hays, CPC, CPMA, CPC-I, CEMC, Coding and Compliance Strategist for the American Academy of Family Physicians

Tuesday, February 21, 2017

CMS awards millions to help small practices succeed in the QPP

The Centers for Medicare & Medicaid Services (CMS) is rolling out a new effort to give clinicians in solo and small group practices on-the-ground training and education about the Quality Payment Program (QPP). CMS has announced $20 million in grants to 11 organizations to provide the services for the first year of a five-year program. Working through the Medicare Access and CHIP Reauthorization Act (MACRA), CMS plans to invest up to an additional $80 million over the remaining four years.

CMS awarded contracts to the following organizations:

• Altarum

• Georgia Medical Care Foundation (GMCF)

• HealthCentric

• Health Services Advisory Group (HSAG)


• Network for Regional Healthcare Improvement (NRHI)

• QSource

• Qualis

• Quality Insights (West Virginia Medical Institute)

• Telligen

• TMF Health Quality Institute

These groups will provide hands-on training to help thousands of small practices, especially those in historically under-resourced areas, including those that are rural, have a shortage of health professionals, or are medically underserved. For example, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the program, including supporting change management and strategic planning and assessing and optimizing health information technology. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices.

To find out if your practice is eligible for this assistance, you can call 1-866-288-8292 from 8 a.m. to 8 p.m. (EST) or email

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

Thursday, February 16, 2017

Executive orders and family medicine

Amid the furor surrounding other executive orders recently signed by President Donald Trump, family physicians may find one on which they can agree.

On Jan. 30, the administration issued an executive order titled, “Reducing Regulation and Controlling Regulatory Costs.” The order establishes a framework designed to reduce the cost of compliance with federal regulations. First, it provides that federal agencies, when proposing a new regulation, must “identify at least two existing regulations to be repealed.” Second, it requires that the incremental cost of any new regulation be “no greater than zero.”

The stated intention of the executive order is to decrease the cost of running a business (such as a family medicine practice), to the extent that regulations from federal agencies contribute to such costs.  The order says that all new regulations must be cost-neutral and that the net impact (new regulation minus the two repealed regulations) cannot increase "incremental costs" on the regulated community. Finally, exceptions will be considered on a case-by-case basis. 

The implementation of the order is left to the Office of Management and Budget (OMB). On Feb. 2, OMB issued to all government agencies a memo containing interim guidance and frequently asked questions on how to implement this order.  This memo clarifies that:

•    The order applies to "significant" regulations. "Significant" is not defined in the guidance, but under a 1993 Executive Order still in effect, a "significant" rule is defined as any that imposes an annual economic cost of $100 million or more.  
•    Government agencies intending to issue a “significant regulatory action” on or before Sep. 30, must first “identify two existing regulatory actions the agency plans to eliminate or propose for elimination” before the new regulation is issued.
•    Agencies must “fully offset total incremental cost” of the new regulation as of Sep. 30.
•    The costs of regulations are “measured as the opportunity cost to society,” defined as "the net benefit [a] resource would have provided in the absence of the requirement."
•    Waivers exist for regulations that address health, safety or financial emergencies. 

Future rules governing Medicare physician payment (such as those implementing the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA) could be shaped by this order. Stay tuned!

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

Wednesday, February 8, 2017

Meaningful use deadlines extended to March 13

It is the season for Medicare program deadline extensions. If you are in the process of reporting your 2016 data for the Medicare Electronic Health Record (EHR) Incentive Program, also known as meaningful use, the deadline has just been extended from Feb. 28 to 11:59 pm (PT) on March 13. The Centers for Medicare & Medicaid Services (CMS) said this extension applies to those eligible professionals looking to avoid a negative payment adjustment on Medicare reimbursements in 2018.  Those participating in the Medicaid EHR Incentive Program should refer to the attestation deadlines in their particular state.  

However, there is still one critical Feb. 28 deadline remaining. If CMS has notified you that your practice failed to successfully demonstrate meaningful use for the 2015 performance year, meaning you are scheduled to receive a negative payment adjustment on all Medicare reimbursements in the associated 2017 payment year, you still must complete and submit a application to request reconsideration by the end of the month. Likewise, if you applied for a hardship exception tied to challenges in the 2015 performance year and your application was denied, you still need to complete a request for reconsideration by Feb. 28 or face negative payment adjustments this year.

The application for reconsideration and instructions related to the application are available on the CMS website for EHR Incentive programs, payment adjustments, and hardships.  For questions about the Reconsideration Application, email

For questions about the Registration and Attestation System, contact the EHR Information Center at 1-888-734-6433 (option 1), which is open Monday through Friday from 6:30 am to 5:30 pm ET.

– Theresa Wilkes, Medical Informatics Strategist for AAFP

Friday, February 3, 2017

Deadline extended for certain PQRS reporting

If you are reporting to the Physician Quality Reporting System (PQRS) using the Electronic Health Record (EHR) method, you now have a little more time to submit your data. The Centers for Medicare & Medicaid Services (CMS) recently announced that it was extending the Feb. 28 deadline for PQRS submission through the EHR or qualified clinical data registry (QCDR) mechanisms.

Eligible professionals (EPs) and groups have until March 31 to submit their 2016 quality reporting document architecture (QRDA) I or III files for the EHR Direct, EHR Data Submission Vendor (DSV), and QCDR reporting mechanisms. Qualified registries and QCDRs that use XML files also have until March 31 to submit. Vendors may have their own individual deadlines that may be earlier. EPs should work directly with their vendors to ensure their data is submitted before the deadline.

EPs who fail to satisfactorily report to PQRS for 2016 will receive the maximum negative payment adjustment in 2018. EPs failing to report will also face the maximum negative payment adjustment for their group size under the Value-Based Payment Modifier Program (VBPM). Payment adjustments for the PQRS and VBPM are separate from those for the Medicare Electronic Health Record Incentive Program (a.k.a “meaningful use”). EPs have until March 13 to submit their meaningful use data. EPs can submit CQMs using the PQRS EHR reporting method or QCDR QRDA III files to fulfill the CQM requirements for both meaningful use and PQRS. EPs can contact the QualityNet Help Desk for questions about PQRS and the EHR Information Center Help Desk (1-888-734-6433, option 1) for questions relating to meaningful use.

The final year for which EPs are required to submit data for PQRS, VBPM, and meaningful use is 2016. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 consolidates these programs into the Quality Payment Program (QPP). The first performance period for the QPP began on Jan. 1. Physicians can learn more about the QPP on the AAFP website or in the latest issue of FPM.

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

Wednesday, January 25, 2017

MIPS help offered for practices in rural and underserved areas

The Centers for Medicare & Medicaid Services (CMS) is inviting small practices that work in rural and medically underserved areas to join a webinar on Wednesday, Feb. 1, at 1:00 p.m. (Eastern Time) to learn more about participation in the Merit-based Incentive Payment System (MIPS) track of the Quality Payment Program.

During the webinar, CMS will provide information about eligibility, how to participate in MIPS in 2017, methods for submitting data to CMS, performance categories, how practices are scored, and other resources for these types of practices.

Participants will also have the opportunity to ask questions during a Q&A session.

Registration is available online:

Space for this webinar is limited, so you are encouraged to register as soon as possible to secure your spot. After you register, you will receive an email message with a webinar link.

For more information on MIPS and the Quality Payment Plan in general, read this article in the latest issue of FPM.

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

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