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  • 01/08/2021 10:05 AM | Rebekah Francis (Administrator)

    CMS confirms new, increased 2021 conversion factor following year-end legislation

    Following legislation signed into law in December, Congress added $3 billion to the Medicare Physician Fee Schedule (PFS) and delayed implementation of HCPCS add-on code G2211 for three years. As a result, the Centers for Medicare & Medicaid Services (CMS) has confirmed that the new 2021 PFS conversion factor will be $34.8931 instead of $32.4085, as previously finalized in the PFS final rule. CMS also updated the 2021 RVU file. We expect to see a formal announcement regarding these developments in the near future. CMS is also expected to communicate the new conversion factor and payment rates to local Medicare Administrative Contractors (MACs), who will update their schedules accordingly. For accurate rates based on your geographic area, we recommend checking with your local MAC.

    MGMA submits comments on CMS prior authorization proposed rule

    MGMA offered comments on the CMS proposed rule requiring a limited number of federal payers to support application programming interface (API) standards. CMS proposed that covered payers provide patients access to their claims information via APIs and support API standards for prior authorization transactions with physician practices. The rule would also require payers to support automated approaches to coverage determinations and transmit to practice EHRs the clinical documentation template for the authorization. CMS also proposed that payers would be given 72 hours to respond to an urgent prior authorization and seven days for all others. MGMA strongly urged CMS to include Medicare Advantage and other payers in the regulation and significantly shorten the time payers would have to respond to practices.

    2020 MIPS data submission portal open; report by March 31

    CMS opened the data submission portal for MIPS clinicians and groups who participated in the 2020 performance year. Data can be submitted until March 31, and you must sign into the Quality Payment Program (QPP) website to report.

    CMS has a variety of resources dedicated to assisting participants with their 2020 data submission in its QPP
    resource library. In addition, MGMA recommends that groups that expect to participate in MIPS for 2021 review recently added guidance that pertains to the 2021 performance period, such as quality measure benchmark files, cost measure information, promoting interoperability measure specifications, and more.

    MGMA to ONC: Delay enforcement of information blocking until after PHE

    In a comment letter to the Office of the National Coordinator for Health Information Technology (ONC), MGMA called on the agency to tie the start of enforcement of the information blocking requirements to the end of the COVID-19 Public Health Emergency (PHE). The association argued that physician practices are focused on meeting the challenges related to the COVID-19 pandemic and need additional time to prepare for the complex new regulatory requirements. MGMA also called on ONC to develop additional guidance to help practices comply with the law.
  • 01/05/2021 10:25 AM | Rebekah Francis (Administrator)

    Year-end legislation summary: What medical groups need to know

    On Dec. 21, Congress passed massive year-end legislation that includes $1.4 trillion in funding for the federal government in FY 2021, an additional $900 billion in COVID-19 stimulus funds, and various other provisions that impact medical groups. President Trump signed the bill into law on Dec. 27.

    In the coming weeks, MGMA expects the Administration will issue guidance on certain provisions of the new law. This guidance is expected to provide more detail into how these provisions will be implemented and the impact on medical groups. As this information becomes available, MGMA will keep medical group practices updated and will be revising resources, such as those published in MGMA’s
    COVID-19 Recovery Center.

    Key provisions of the law include the following:

    Medicare payment

    • Increases Medicare payments across the board for CY 2021 from what was finalized in the 2021 Physician Fee Schedule (PFS) by adding $3 billion into the PFS and delaying payment of HCPCS add-on code G2211 for three years. MGMA expects that the Centers for Medicare & Medicaid Services (CMS) will release information regarding the updated payments for 2021 once it factors in the 3.75% increase to the PFS and calculates the impact of delaying G2211. We expect CMS to communicate the new conversion factor and new payment rates to local Medicare Administrative Contractors, who will update their schedules accordingly. These payment increases follow significant MGMA advocacy and will serve to offset cuts previously slated for Jan. 1, 2021. 
    • Temporarily suspends the 2% Medicare sequester from Jan. 1 through March 31, 2021. MGMA advocated for an extension of the current moratorium on Medicare sequestration authorized in the Coronavirus Aid, Relief, and Economic Security (CARES) Act.
    • Extends the work geographic index floor under the Medicare program through Dec. 31, 2023.
    • Expands access to mental health services furnished through telehealth past the expiration of the COVID-19 public health emergency. MGMA expects to see further guidance from CMS on this policy change.

    Paycheck Protection Program (PPP)

    • Extends and modifies the PPP to provide further flexibilities, such as:
      • A simplified loan forgiveness application process for loans under $150,000;
      • Clarification that loan recipients may deduct forgiven PPP loans;
      • The creation of a “PPP second draw” loan for businesses that meet certain criteria;
      • The allowance of additional eligible and forgivable covered expenses;
      • The ability for certain 501(c)(6) organizations to qualify for a PPP loan; and
      • The ability to elect a covered period ending between 8 and 24 weeks after loan origination.
    • MGMA expects the U.S. Department of the Treasury to issue and update guidance to reflect the modifications made to the PPP in the coming days.

    Provider Relief Fund (PRF)

    • Adds $3 billion to the $175 billion PRF and clarifies how recipients can use funds to cover “lost revenue” attributable to COVID-19. The new law allows providers to calculate lost revenues using a budgeted-to-actual revenue comparison, rather than actual year-over-year comparisons as currently required by Department of Health & Human Services (HHS) guidance.
    • This change, as well as the addition of funds, is welcome news; however, it remains to be seen how HHS will implement new clarification. Group practices should continue to monitor the PRF website for updates based on the new legislation in the coming days or weeks. 

    FFCRA paid sick and family leave

    • Extends the refundable payroll tax credits for paid sick and family leave enacted in the Families First Coronavirus Reponses Act (FFCRA) through March 31, 2021, so employers may choose to continue offering paid leave to their employees. It does not, however, require employers to extend FFCRA paid sick and family leave past Dec. 31, 2020. 

    Surprise billing

    • Provides patient protections from out-of-network medical bills. Nonparticipating providers at emergency facilities (or a participating provider at a nonparticipating emergency facility) will not be permitted to bill a patient beyond the allowed cost-sharing amount. Instead, the patient’s health plan will make an initial payment directly to the provider or issue a notice of denial. If the provider or plan is not satisfied with the payment, either party may initiate an Independent Dispute Resolution (IDR) process, which is overseen by a third party entity who has no affiliation with the provider or payer. Each party then submits a payment offer for consideration by the IDR entity, who selects one prevailing offer as the final payment amount.
    • This provision is set to go into effect in 2022 and will involve rulemaking from the Administration to provide certain implementation details. Following MGMA advocacy, at the last minute lawmakers included improvements to the IDR process.

    Alternative Payment Models (APMs)

    • Freezes the 2020 qualifying participant thresholds required to achieve APM benefits, such as the 5% lump sum bonus. These thresholds were set to increase in 2021 to unrealistic levels, however pursuant to this legislation, will remain at the 2020 thresholds (at least 50% of Medicare Part B payments or at least 35% of Medicare patients through an advanced APM entity) through 2023. MGMA strongly supported maintaining 2020 thresholds in 2021 and beyond to allow more group practices to realize the benefits of APM participation.
  • 12/17/2020 9:10 AM | Rebekah Francis (Administrator)

    HHS begins issuing Phase 3 Provider Relief Fund payments 

    The Department of Health & Human Services (HHS) announced it is beginning distribution of Phase 3 Provider Relief Fund (PRF) payments on Dec. 16, which will continue through January. The Phase 3 distribution considers actual revenue losses and expenses attributable to COVID-19 and follows two earlier General Distributions to group practices and other healthcare entities.

    While HHS has not published a formula for how it calculated Phase 3 payments, yesterday’s announcement indicated that this funding will meet “up to 88 percent of [a provider’s] reported losses” from COVID-19 in the first half of the year. Previous General Distributions endeavored to provide entities with a baseline payment of 2% of annual revenue from patient care. Practices that applied for Phase 3 should watch for payments and not be alarmed if payments result in amounts that exceed this 2% figure. MGMA will share updates with members as they are released. Additional information about Phase 3 includes:

    • Phase 3 funds are being distributed pursuant to applications submitted between Oct. 5 and Nov. 6. Payments are based in part on how many providers applied, which explains the delay in issuing funding.
    • HHS increased the amount of available Phase 3 funding from $20 billion to $24.5 billion.

    Payments are being distributed to over 70,000 providers. Of these, it is estimated that 35,000 applicants will not receive an additional payment either because they experienced no change in revenues or net expenses or because they already received funds that equal or exceed reimbursement of 88% of reported losses.

    MIPS hardship applications available for 2020 performance year

    Group practices experiencing issues with meeting 2020 MIPS reporting requirements can apply for a hardship exception that, if approved, will re-weight any or all performance categories and hold clinicians harmless for non-reporting. There are two separate applications available:

    • The Extreme and Uncontrollable Circumstances Exception application allows a clinician, group practice, or APM entity to request reweighting for any or all performance categories if they experience circumstances beyond their control, such as the COVID-19 public health emergency. The deadline to apply for this exception is Feb. 1, 2021.
    • The MIPS Promoting Interoperability Performance Category Hardship Exception application is available to request reweighting for this category only. MIPS clinicians or group practices can submit an application by Dec. 31, 2020, citing one of the following reasons:
      • The group is a small practice
      • EHR technology is decertified
      • Insufficient internet connectivity
      • Lack control over the availability of CEHRT

    Extreme and uncontrollable circumstances

    MGMA calls on Congress to mitigate HIPAA fines for medical groups

    MGMA joined six other leading healthcare organizations, including the American Medical Association and American Hospital Association, urging Senate leaders to support H.R. 7898. Specifically, this legislation would require the HHS Office for Civil Rights (OCR) to consider use of recognized security best practices by a medical group when assessing fines and audits related to HIPAA. The legislation gives much-needed protection to medical groups who follow recognized security practices to fend off cyberattacks by acknowledging that organizations who have been acting in good faith should not be penalized by OCR. Earlier this month, the House of Representatives passed the legislation on a voice vote. Access MGMA cybersecurity resources here.

  • 12/14/2020 12:49 PM | Rebekah Francis (Administrator)

    Tell Congress to support medical groups in year-end legislation!

    As Congress continues to negotiate an end-of-year legislative package, it is essential for lawmakers to hear from medical group practices on two issues that could impact the financial viability of your organization. Help #MGMAAdvocacy by sending your congressional representatives letters urging them to:

    • Prevent Medicare cuts: Due to budget neutrality requirements, the finalized payment increases to office/outpatient E/M services and other payment policies will result in a 10.2% reduction to the 2021 Medicare physician fee schedule conversion factor. While MGMA is supportive of streamlined documentation policies and payment increases to office visits, we strongly oppose the resulting payment cuts to many specialties. Urge Congress to pass legislation that would prevent Medicare reimbursement cuts before they begin.

    Suspend Medicare sequestration: The CARES Act, signed into law in March, offered much-needed relief to medical groups by placing a temporary moratorium on the 2% Medicare sequestration cut. Unfortunately, the Medicare sequestration cuts are scheduled to return Jan. 1, 2021. Urge Congress to pass legislation before the end of the year to delay reinstatement of the MGMA-opposed sequestration cuts until the end of the COVID-19 public health emergency.

    Advanced APMs: Check for missing 2018 payments by Dec. 13 

    Group practices that participated in an advanced alternative payment model (APM) in 2018 and earned the 5% bonus payment should review CMS' list of qualifying participants (QPs) who remain unpaid and follow instructions on how to claim payments if their QPs are listed. More information can be found in this zip file. CMS distributed 2018 APM incentive payments in September, but the agency indicated there are many QPs it has been unable to locate in order to issue the incentive payments.

    Following MGMA advocacy, CMS extended the deadline to provide updated information from Nov. 13 to Dec. 13. While we urged the agency to eliminate the deadline altogether and pursue more extensive outreach, we are pleased the agency is giving unpaid clinicians more time to claim the payments they earned. Even group practices that have already received an APM bonus payment should check the file for their clinicians' names, as the payments received earlier may have omitted certain clinicians' payments.
  • 12/02/2020 11:06 AM | Rebekah Francis (Administrator)

    The Centers for Medicare & Medicaid Services (CMS) released the final 2021 Medicare physician fee schedule (PFS) rule this evening, which includes changes to the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) participation options and requirements for 2021. The final rule:

    • Sets the CY 2021 PFS conversion factor at $32.41 and the CY 2021 national average anesthesia conversion factor at $20.0547. MGMA is advocating for a legislative fix to address the reimbursement cuts resulting from the lower conversion factor;
    • Generally confirms E/M office visit documentation guidelines and payment changes finalized in the 2020 PFS;
    • Modestly expands telehealth coverage; and
    • Establishes MIPS reporting requirements for 2021 and sets the performance threshold at 60 points.
    For more information, review the physician payment fact sheet and QPP zip file associated with the 2021 final PFS. MGMA will analyze the final rule and provide a detailed analysis as a member benefit. MGMA will also provide further education on this complex regulation during our 2021 Medicare Outlook member-benefit webinar on Thursday, Dec. 10 at 1 pm ET.
  • 11/24/2020 11:29 AM | Rebekah Francis (Administrator)

    On Friday, the Trump Administration issued an interim final rule implementing a new mandatory, nationwide model for Medicare suppliers, including group practices. The Most Favored Nation (MFN) Model will operate for seven years, beginning on Jan. 1, 2021, and will include the following elements:

    • Instead of paying providers that administer drugs based on the average sales price (ASP) in the U.S., Medicare will pay for Medicare Part B drugs based on a blended formula that includes the lowest adjusted international price (the “MFN Price”) and the ASP as well as a flat add-on amount per dose. The MFN Price will be phased in over the span of four years, but is subject to an accelerated timeline if U.S. prices rise faster than the MFN Price and inflation.
    • The MFN Model will focus on a list of 50 drugs that encompass a high percentage of Medicare Part B spending.

    Due to the way in which the Administration circumvented the typical rulemaking process in issuing this regulation, it is possible that it will face legal challenges. MGMA is assessing the impact on medical group practices and will monitor future developments.

  • 11/24/2020 11:29 AM | Rebekah Francis (Administrator)

    Changes to the physician self-referral “Stark” law

    On Friday, Nov. 20, the Centers for Medicare & Medicaid Services announced changes to the Physician Self-Referral Law, also known as the “Stark Law,” as well as revisions under the Anti-Kickback Statute. Historically, the Stark Law has prohibited physicians from making referrals to entities for certain healthcare services paid by Medicare if the physician has a financial relationship with the entity. MGMA and other stakeholder groups have long argued these rules impede the nation’s transition to value-based reimbursement. The new Stark Law rule finalizes many of the proposed policies from the notice of proposed rulemaking issued in October 2019, including:

    • Creating exceptions for value-based arrangements that permit physicians and other providers to design and enter into value-based arrangements without violating the physician self-referral law;
    • Offering additional guidance on key requirements of existing exceptions to the physician self-referral law; and
    • Providing protection for non-abusive, beneficial arrangements that apply regardless of whether the parties operate in a fee-for-service or value-based payment system, such as donations of cybersecurity technology that safeguard the integrity of the healthcare ecosystem.
    In response to these changes, MGMA released a  statement and will be closely evaluating the impacts these changes might have on medical group practices
  • 11/19/2020 11:54 AM | Rebekah Francis (Administrator)

    MGMA joined over 100 other organizations in urging the Centers for Medicare & Medicaid Services (CMS) and major commercial health plans to immediately implement and pay for CPT code 99072 with no patient cost-sharing during the COVID-19 public health emergency (PHE). The CPT Editorial Panel recently approved CPT code 99072 to cover additional supplies, materials, and clinical staff time above the typical practice expenses included in an office visit when performed during the COVID-19 PHE. Reimbursement for this code is intended to help compensate practices for these additional expenses and provide financial support so that practices can continue to focus on caring for their patients during the pandemic.

  • 11/19/2020 11:53 AM | Rebekah Francis (Administrator)

    MGMA to Congress: Extend moratorium on sequestration

    MGMA sent a letter to Congress urging an extension to the current moratorium on the Medicare sequester through the end of the COVID-19 PHE. Sequestration is a budget enforcement tool that uses the automatic reduction of federal spending to encourage certain budget objectives or goals. Since 2013, it has resulted in a 2% across-the-board cut in Medicare provider payments. The CARES Act, signed into law in March, temporarily suspended sequestration through the end of this year. MGMA has long opposed applying the sequester to Medicare reimbursement and encourages extending the CARES Act moratorium beyond its current expiration date.

    MGMA urges delay and reevaluation of AUC program 

    MGMA joined more than 20 physician organizations in a letter calling on Congress to statutorily delay the Appropriate Use Criteria (AUC) program. The AUC program requires professionals ordering certain advanced imaging tests for Medicare patients to consult a qualified Clinical Decision Support Mechanism to establish if the test is appropriate for the patient’s condition. The rendering professional will be required to include the AUC consultation code on their Medicare claim. Although CMS announced it has extended the educational and operations testing period for the AUC program through 2021, the letter calls on Congress to delay the program indefinitely and find a more feasible, less burdensome approach to reward Medicare clinicians who provide high-quality, clinically appropriate care. Access the MGMA member-benefit AUC Toolkit for more information on the program.

  • 11/12/2020 5:08 PM | Rebekah Francis (Administrator)

    U.S. Supreme Court hears ACA challenge

    On Nov. 10, the U.S. Supreme Court heard oral arguments in a case challenging the Affordable Care Act (ACA). MGMA prepared a summary of the case for members on our ACA landing page, which we will continue to update as developments occur. A decision is not expected until 2021.

    The case, captioned California v. Texas, centers on the ACA’s individual mandate to maintain minimum health coverage and its tax penalty. Following legislation that set the tax penalty to zero dollars starting in 2019, plaintiffs challenged the validity of the ACA and argued that, if the individual mandate is unconstitutional, the rest of the law is as well. Statements made by several justices during oral arguments implied the Court is unlikely to overturn the entire law, but the actual outcome of the case remains unknown until an opinion is issued.

    Last chance: Tell your lawmakers to pass COVID-19 relief legislation this year  

    Following the 2020 election, Congress is returning to Washington, D.C. for one final “lame duck” session of the 116th Congress. There are limited legislative working days left in the year, making it imperative that physician practices reach out to their lawmakers to urge them to pass COVID-19 relief legislation.

    Send a letter to your senators and representatives urging them to include the following in any final legislation:

    • direct financial support to medical groups,
    • continue telehealth flexibilities past the COVID-19 public health emergency,
    • address Medicare payment cuts to certain specialties; and

    reopen and amend aspects of the Paycheck Protection Program.

    Don’t miss these important MIPS deadlines 

    With the end of the year approaching, MIPS-participating clinicians and groups need to be aware of these upcoming
    MIPS deadlines.

    • Dec. 31 – 2020 Promoting Interoperability Hardship Exception and Extreme and Uncontrollable Circumstances Exception applications are due for clinicians and groups who believe they are eligible for a re-weighting of one or more performance categories.
    • Dec. 31 – 2021 virtual group election period closes.
    • Jan. 4 – 2020 MIPS performance year data submission window opens.
    • March 1 - Deadline for CMS to receive 2020 claims data for the Quality performance category. Claims must be received by CMS within 60 days of the end of the performance period. Deadline dates vary to submit claims. Check with your MAC for specific instructions.
    • March 31 - 2020 MIPS performance year data submission window closes.
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