As we have written before, you, the administrator, have the ability to affect patient care. Strong leadership skills empower your staff to reach your organization’s goals by setting the right example and making your employees feel heard. We encourage Association members to reach their leadership potential to stay competitive in the marketplace and to better serve their patients.

Ron Menaker, Ed. D., MBA, FACMPE, CPA, MGMA-ACMPE member, administrator, Mayo Clinic, Rochester, Minn., outlined how leadership competencies enhance your organization in his session “Leadership and succession planning” at this year’s Anesthesia Administration Assembly (AAA) in Miami.

Here are four ways to improve your leadership skills:

Show humility and empathy

Menaker says strong leaders have emotional intelligence, which means being able to show vulnerability and modesty to your employees and to empathize with their needs and concerns.

“Empathy means listening to what’s not being said,” he says.

Menaker gives the example from early on in his career of one of his employees who was upset that Menaker only seemed to care about his productivity, not about him as a person.

“He said to me, ‘whenever we meet, you just want to talk about the numbers,’” he says. “I realized that if I only care about the numbers, then I don’t care about the people.”

Menaker says it’s not difficult to form positive relationships with your staff that help them feel valued and empower them to do their jobs at the highest level. When evaluating your staff relationships, he suggests asking yourself questions such as “What mistakes have you made that have damaged relationships?” and “How do you maintain an openness to the ideas of others?”

"A lack of time or structure is not an excuse,” he adds. “It doesn’t take that much time to connect with your staff.”

Understand your organizational strategy

Menaker says leaders should make sure that every new project or implementation in your practice contributes to the organizational strategy.

This requires you to have a full understanding of what your organization’s mission, vision and values are and how your role contributes to each of them. By understanding the organizational strategy, it will be easier for you to lead your staff in the right direction and make sure that their jobs — and yours — align with the goals of the practice.

Promote positive change management

Change is inevitable, but the way you, as a leader, manage that change can affect the outcome. Menaker says a common misconception is assuming your staff is resistant to change if they’re not enthusiastic about new initiatives.

“People don’t resist change, they resist being changed,” he says.

Instead of presenting changes to your staff, such as a new technology or a new scheduling policy, incorporate your team in the process. This gives them ownership and makes them a part of the solution.

Also, consider how you handle change. Menaker recommends asking yourself these questions:

• How do you maintain openness to new ideas?
• How do you balance inclusiveness with implementing change quickly?
• Do you struggle with too much or too little change?

Know why leaders get derailed

Menaker says managers often get derailed from being an effective leader when they have problems with interpersonal relationships. Characteristics of someone with interpersonal relationship problems may include:

• Insensitivity to others
• Arrogance
• Isolating yourself from your team
• Being untrustworthy

Be honest with yourself if you have issues with workplace relationships, and work on improving how you relate to your staff.

More from mgma.com:
For a healthy practice, be a vulnerable leader
Mentorship: Enhance your profession, improve your practice
Common management derailers and how to fix them

Many physician residency programs finish in June, so now is an opportune time to find a recent graduate who’s a good fit for your practice. Before you set that start date, you’ll want to think about credentialing.

“The problem is that many professionals are in a reactive mode when it comes to credentialing,” says Donna Knapp, MA, FACMPE, independent consultant, MGMA Health Care Consulting Group. “It should be a continuous process with dedicated resources.”

Established physicians moving from one practice to another can be difficult enough to credential, but brand-new physicians have their own set of intricacies to work through.

“Most insurance companies will tell you that there’s about a 60- to 90-day period between the receipt of a completed application and a brand-new doctor being approved,” says Richard Longo, FACMPE, MGMA-ACMPE member, senior consultant, Devon Health Services Inc., Pittsburgh, Pa. “To be safe, estimate 90 days.”

Longo says he’s tried to plan hiring for physicians accordingly to ensure that the physician can start billing payers on their very first day.

“Most insurance companies will not retroactively reimburse,” he notes.

If you can’t set up the new physician prior to their start date, until the physician is enrolled, patients should be scheduled with another credentialed physician. If the patient is scheduled to see a non-credentialed physician, the patient should be advised that the physician is not a provider for their plan. If the patient has out of network benefits, the services may be covered at a reduced rate or services will be at the patient’s expense.

A new physician will need the following:

A national provider identifier (NPI)

This is obtained through the Centers for Medicare & Medicaid Services’ (CMS) National Plan and Provider Enumeration System. If an application for an NPI has been submitted online, CMS estimates that the provider should receive their 10-digit number within 10 business days, but again, it’s best to err on the side of caution and give yourself a larger window of time if you can.

Credentialing requirements for each health plan

Many follow the National Committee for Quality Assurance (NCQA) guidelines, which require that physicians have a license and malpractice coverage before they can apply for credentialing.

Privilege requirements for contracted hospitals

Some payers also require that physicians carry clinical privileges at a hospital, so that’s another step you might have to take.

You may also need:

• Proof of education
• Valid Drug Enforcement Administration certification
• Proof of board certification

It helps to start preparing as early as you possibly can — getting all of the necessary paperwork and proof of eligibility can take some time.

Longo also suggests that practices consider credentialing when drawing up physician contracts and physician agreements.

“It should be spelled out in terms of what the criteria for credentialing is going to be, and it should also be spelled out that failure to meet the practice’s credentialing and privileging process means that you wouldn’t satisfy that criteria, therefore you couldn’t come in to the practice,” he adds.

Read more about how to create an ongoing credentialing process in “Deep dive: What lies beneath the surface?” in the April 2013 issue of Connexion magazine.

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Understand payer requirements for billing non-physician providers
Define patient panels to improve practice flow, patient care 

Directors hit some of healthcare’s biggest challenges head-on in a recent documentary, “Escape Fire: The fight to rescue American healthcare,” which gives the public a glimpse into the American healthcare system and features an MGMA-ACMPE member’s practice.

The documentary, released last October, addresses issues related to the fee-for-service model that ring true for many practice administrators — mainly, the challenge of balancing quality care with rising costs and the productivity demands to meet those costs.

Addressing the problem

The film starts off with scenes of Erin Martin, MD, a busy primary care physician who struggles with a heavy patient load — 20 scheduled patients and five or six on the waiting list — at her community-based clinic in rural Oregon.

Many of Martin’s patients seek treatment for chronic diseases, such as diabetes, and mental health issues, such as depression and anxiety. However, because she can spend only a limited amount of time with them, she shares her fear that she can only treat their symptoms and not the causes of their conditions.

“We end up being this revolving door,” she says in the documentary. “You try and fix one thing, but they come back for the same thing over and over and over. You never get to the bottom of what’s causing all of these problems.”

Martin’s frustration echoes a cornerstone of patient-centered care: “As a primary care physician, we’re supposed to be the ones who make sure that people don’t get sick and that they have everything they need to maintain health,” she says. However, she adds that her inability to truly care for patients is demoralizing, which leads to her decision to leave clinic.

The administrator perspective

The film shows Martin a year later, working at a new practice where she is able to spend more time with patients and address the cause of chronic disease. While Martin is pleased with her new environment and the ability to practice medicine in a way that benefits patients, practice administrator, Cindy Robertson, MGMA-ACMPE member, shares concerns about meeting the practice’s financial obligations, which will require Martin to see more patients.

Robertson, who works at NorthShore Medical Group, White Salmon, Wash., explains that the other physicians in the group have covered Martin’s costs while she settles in and ramps up her schedule, but dwindling primary care reimbursement threatens to shut the practice doors if the doctors do not see more patients. It's a paradox many practice professionals face. If they don't increase their patient loads – which means doctors spend less time with patients overall – they'll struggle financially and potentially go out of business, which ends up hindering patients' access to the care they need.

The Escape Fire documentary highlights this issue during a scene in which Robertson is meeting with her physicians to discuss how to manage upcoming Medicaid reimbursement cuts.

“To make up that difference we’re changing to shorter appointments next week,” she says. “It’s a financial necessity; that’s the only reason we’re making the change.”

Robertson got involved with the documentary when the directors were filming Martin in her new practice and started asking questions about the financial aspects of medicine.

Robertson, who says she is pleased with her part in the documentary, hopes it will shed light on the realities of working in healthcare.

"It’s uncomfortable to publically state that we believe we’re working in a fundamentally broken system,” she says. “But the film accurately portrayed the very difficult day-to-day challenges we’re facing in primary care.”

The film shows other examples of a healthcare system built on short-term treatment vs. long-term prevention, including a woman who received more than 25 cardiac catheterizations and seven stents, many of which could have been avoided with lifestyle changes; and Robert Yates, an infantryman who returns from Afghanistan with immense physical and psychological injuries, including an addiction to prescribed narcotics.

Escape Fire, which takes its name from the book by Don Berwick, MD, former Centers for Medicare & Medicaid Services Administrator, advocates for a healthcare system focused on disease prevention and healthy lifestyle changes, such as the military’s acupuncture program to provide an alternative to pain medication and Dean Ornish’s holistic, nutrition-based approach to healing.

The documentary does a good job of drawing attention to the need for healthcare professionals to focus on the patient — a viewpoint the Association stands behind — but it does not address the changes industry-wide to move the current fee-for-service system to one that is more patient-centered and cost-effective for practices and patients,
“We hope the film will help provoke positive change,” Robertson says. “We need a different way of doing things.”

Susan Turney, MD, MS, FACMPE, FACP, president and CEO, MGMA-ACMPE, agrees.

“Healthcare professionals are in the driver’s seat when it comes to prompting meaningful change to our healthcare system. Physicians and their healthcare teams are in a difficult position with conflicting financial incentives and government regulations, but they have an innate instinct to put patients first. As experts in processes that relate to providing the best care, practice administrators are taking leadership roles to create and streamline processes that improve the patient experience and support providers.”

As we move to a new era of healthcare delivery, programs such as Health Information Exchanges, value-based purchasing, health literacy programs and chronic disease registries will maximize the time physicians have with patients to improve their health.

How we can help

The Association supports the need for payment reform and improved patient care, and works to provide information and tools to help practices address those issues and succeed in a new healthcare environment.

Resources, such as the CAQH electronic funds transfer (EFT) enrollment tool, our patient satisfaction benchmarking tool and our new webinar on the Patient Protection and Affordable Care Act’s (ACA) operating rule requirements help practice professionals prepare for and manage these changes administratively and clinically.

Have you seen Escape Fire? If so, share your thoughts in the comments section below.

Ron Menaker, Ed. D., MBA, FACMPE, CPA, administrator, Mayo Clinic, Rochester, Minn., attributes much of his career success to the relationships he formed through mentoring and Association involvement.

Menaker reflects fondly on his mentor relationships — which he calls “positive and selfless” — and believes that forming strong connections with fellow healthcare leaders not only provides personal fulfillment but can also grow your career and add value to your role as an administrator.

Mentorship doesn’t necessarily require an invested one-on-one relationship; it can also mean answering a question from someone less experienced than you or reaching out to someone who has made strides in their organization that you hope to make, which is why Menaker is working to build the network of potential mentors through his 100 Fellows campaign.

Emerging models of care provide a greater need to connect and share ideas more rapidly in the new healthcare environment. Developing relationships will be more crucial to the success of your organizations, Menaker adds.

In-person education

Menaker attributes much of his career growth to the relationships he's formed at MGMA conferences over the years. He says it's key to get out of your silo and always be in a position where you can meet people. He describes it as mentorship through networking.

"Meet people just to meet them,” he says. “This is how communities are built.”

Get involved

Administrators at the Mayo Clinic are required to rotate specialties, which means Menaker is essentially faced with a new job every several years.

“My best friend is the MGMA Member Community,” he says. “When I rotate, I lean on the MGMA assemblies and societies for information on my new specialty.”

Assemblies and societies help you connect to those in a similar specialty or practice size, and the Member Community offers members a place to pose questions, search for members in the directory and reach out to those who may benefit from your expertise.

“The nature of MGMA-ACMPE makes it easy to connect with people who have interests or needs that are similar to your own,” Menaker says.

Professional development through ACMPE board certification and Fellowship

Shifts in the industry — such as mergers and acquisitions and the rise of accountable care and value-based payments — mean practice administrators might do business differently. It will behoove them, Menaker says, to seek advice from others and pursue continuing education to be a successful leader and better serve their patients in a new era of healthcare.

“When I think about the challenges that we will face in medical group management, we will need Fellowship more than ever,” he adds. “As members of an Association, we’re all in this together.”

The ACMPE certification and Fellowship program strengthens your skills and provides ongoing education and mentorship to help prepare you to be an effective leader of your healthcare organization.

100 Fellows

While Menaker was finishing the last stages of the Fellow process he received a special phone call from Bill Amery, FACMPE, who at the time was the chair of the Fellow papers committee. Even though they did not have a prior relationship, he called Menaker after reviewing his case study. He advised him and provided some very sensitive coaching and support.

“I struggled with my paper, and he essentially said to me, ‘keep the faith; you’ll get there,’” Menaker says. “I took another run at it and did it successfully.”

Menaker’s beneficial mentoring relationships inspired him to create the 100 Fellows campaign with a goal to grow the ACMPE Fellowship by 100 by this year’s MGMA Annual Conference, Oct. 6-9, in San Diego.

Gaining 100 new Fellows would increase the Fellow pool by 15 percent, which, Menaker adds, means more individuals to give back to the profession through networking, continuing education and mentorship.

Mentorship isn’t limited to those with long tenures in the industry, and Menaker urges everyone to think about how you can reach out to someone else.

“We’re all in a position to mentor,” he says. “A mentor is an individual who knows things that you don’t and can join you on your leadership journey.”

Registration for the MGMA 2013 Annual Conference opens at the end of May. Sign up to receive an email reminder to register.

Inpatient hospital charges can be a mixed blessing for medical practices: On one hand, physicians generate income with little to no overhead — on the other hand, providers don’t always submit charges in a timely manner, according to a recent discussion on the MGMA Member Community. Members say this issue leads to charge lag - money that could have earned interest in practice accounts is uncollected as the charges float in limbo.

Specialty specifics

Inpatient charges come with a host of other complications, too, depending on specialty. Sarah Holt, PhD, MD, FACMPE, practice executive, Cape Girardeau Surgical Clinic, Mo., says that before a practice coder can process a claim for her practice, they need a surgical op (operating) note.

“You have to have someone charged with making sure that they receive that op note in a timely way,” she says. “You really can’t charge before the op note is done or you may have to wait for pathology. For example, if there is a situation where there might have been a malignant tumor, you have to know that it’s malignant before the charge can be placed, even though you have the op note.”

Consider who else is involved

It’s also important to get those claims in quickly because payers will start to compare your claims against those of the other participants in the surgery.

“If you’re a surgeon, and you get your charge in quickly and the anesthesiologist doesn’t have theirs in yet, the anesthesiology code will have to match the CPT code the surgeon put in, and the diagnosis has to match the surgeon’s diagnosis,” she explains. “But if the anesthesiologist gets their claim in first, and let’s say they take their information off the surgical schedule — but more was done in the surgery than is listed in the schedule, and your surgeon is claiming it - then the insurance company will question that claim."

Inaccuracies in A/R metrics

Delays can also cause problems with a practice’s accounts receivable (A/R) metrics, says Laura Palmer, FACMPE, senior industry analyst, MGMA-ACMPE.

“If entering the charges is delayed,” she says, “the reports that run from the original date of service will be impacted by the delays. If you run reports from the date of posting or date of claim, the A/R will not reflect the true aging from the time of service. The longer the delay in entering and billing the charges, the higher the days in A/R will become. The longer you wait to bill after the service is provided, the more difficult it is to collect. The staff has less time to appeal denials or incorrectly paid claims, and it’s more challenging to collect from patients.”

Palmer suggests creating an appointment schedule for the hospital on a device, index card or sheet with the patient’s names; the physician will mark the level of service and diagnosis for each patient, and then the device, index card or sheet is given to the billing staff for data entry. This is a basic method for getting a handle on inpatient charges.

Learn more from Holt at the MGMA 2013 Annual Conference, Oct. 6-9, in San Diego, where she will present “10 Things Doctors Need to Know to Increase Revenue That Only YOU Can Teach!”

Members, look for more options for streamlining your inpatient charge processes in an upcoming issue of MGMA Connexion magazine.

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In healthcare, small actions have ripple effects on providers and on patients' health. As a physician who has worked in practice management, I have seen how the work of practice administrators affects patients' health. Efficient scheduling, effective communication, the timely collection and analysis of data – each piece of the operations puzzle intersects to ensure better patient outcomes.

Our new (free) editorial supplement, “Ripple Effects,”highlights a few ways in which administrators support the delivery of patient-centered care, a concept we researched in the Patient-Centered Care: 2012 Status and Prospects Report. The term is used freely these days for all practice environments, but the ability to live up to patient-centered promises relies on strategic practice management, a topic that rarely grabs consumer headlines but has a dramatic effect on patient care.

 We explore these concepts at our upcoming Patient-Centered Medical Home Program, April 21-23 in Chicago, and we learned in the report that patient-centered processes enable care teams to:

• Enroll patients in chronic disease registries
• Exchange clinical information electronically with everyone involved in a patient’s care
•  Use multidisciplinary care teams directed by providers who manage a patient’s care

The report, which continues Association research from 2011, identifies tell-tale characteristics of patient-centered groups, including the ability to build processes that support these actions:

• Communicate medical test results in a timely manner: Informing patients about their clinical results in terms they understand leads to better care and health outcomes, and it eliminates unnecessary worry.
•  Involve patients and caregivers in an advisory capacity: Creating a venue for patients and their family members to provide perspectives improves patient engagement.

The article “Walking the walk on patient-centered care” shared results from the report and illustrated the importance of customizing group operations that cater to patients, communicating in ways that engage them and prompt questions, and soliciting their feedback to ensure you meet their needs. We didn’t have to look far in our membership to find examples of administrators who prioritize patient involvement, a task in the “Patient Care Systems” domain from the Body of Knowledge for Medical Practice Management (BOK).

The efforts are beneficial for all parties involved, says Ron Menaker, Ed.D., MBA, FACMPE, CPA, administrator, Mayo Clinic, Rochester, Minn. He has been impressed with the accomplishments made by a patient advisory group created in 2008 for Mayo’s cardiology group.

“They gave us a better understanding of how we could interact with patients using the portal, which now has more than 30,000 cardiology patients,” Menaker says. “We started with a blank slate and asked a series of questions about the ideal way we could relate to them. The result has been a better design of outpatient processes.”

The patient advisory group, which meets monthly and comprises 10 to 20 patients and family members, has reviewed safety enhancements and educational materials and helped design new care processes. It is evidence of Mayo’s commitment to patients, says Menaker, who adds, “We not only say patient needs come first, we actively live that value. We solicit advice in an active, engaged way.”

That, I believe, is the true definition of patient-centered care, and it requires a team effort.

Providers are on the front lines of care, and practice managers support their work and help facilitate better outcomes. That potential — to influence patient health — is what draws us to this field. It motivates us to challenge the status quo and to raise the bar on high-quality healthcare delivery. When you consider the fact that there are 1 billion patient office visits each year, you can almost hear the ripple effects of our work.

Share examples of how you, as a practice administrator, affect patient care in the comments section below.

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Using non-physician providers (NPPs) is an effective way to balance provider workload and improve patient access as group practice professionals prepare for the influx of 30 million new patients with implementation of the Patient Protection and Affordable Care Act. However NPPs can put you at risk for noncompliance, as every health plan — including Medicare —has its own rules regarding NPP billing, and each state has its own laws for NPP licensing and scope of practice.

“After working in medical practices for 30 years, I’m no longer surprised when I hear situations where practices have been billing incorrectly for work performed by NPPs,” says Laura Palmer, FACMPE, senior industry analyst, MGMA-ACMPE, in her webinar, Using non-physician providers in your practice. Billing was one of three content areas covered in the webinar, which is available on-demand, and attracted hundreds of professionals.

Understanding your payers’ various billing policies for NPPs, outlined below, may help you avoid compliance issues:

“Incident to” billing

Medicare offers two options: “Incident to” billing or by independently credentialing them and directly billing Medicare with an NPP’s own Nation Provider Identifier (NPI) Many practices do a hybrid of both.

“Incident to” billing allows services provided by auxiliary personnel (such as NPPs) to be billed under the physician’s NPI. Services must be performed under a physician’s direct supervision or while a physician physically present in the same office suite.

Additionally, to qualify as “incident to,” services must be commonly furnished in the physician’s office or clinic, and must be an integral part of a Medicare patient’s normal course of treatment, during which a physician personally performed the initial service and remains actively involved in the course of treatment, according to the Centers for Medicare and Medicaid Services (CMS).

“Incident to” billing can provide reimbursement at a higher rate, since you’re billing under a physician and will receive the physician rate, but in some cases it can be difficult to do administratively. Get more specifics about this in the May/June issue of MGMA Connexion magazine.

Directly billing Medicare with NPI

Unless all services fall under the “incident to” definition, NPPs are required to complete appropriate Medicare enrollment forms, such as the CMS-855I application, to be paid for providing care to Medicare beneficiaries. Independently credentialing NPPs may be less administrative work, but you will receive a lower reimbursement because NPP services are reimbursed at a lower rate than the Medicare physician fee schedule rate. Medicare reimburses physician assistants and nurse practitioners at 85 percent of the physician fee schedule rate.

“We chose to fully credential our NPP,” says Barbara Tauscher, MGMA-ACMPE member, executive director, Gastroenterology Specialists of (Oregon City) Oregon. “The ‘incident to’ rules were too much of an administrative burden.”

Tauscher explains that if a physician was present at the group in the morning and the other “incident to” criteria were met, the NPP could bill for appointments under that physician’s NPI. However, oftentimes the physician would leave to see patients at the hospital in the middle of the day. The NPP would not be able to bill “incident to” using that physician’s NPI as the appropriate supervising physician was not physically present.

Private payer billing

Third party payers generally require their own credentialing of NPPs, and reimburse at a lower rate than physicians, Palmer says. The American College of Physicians recommends that practices understand the difference between payers that do not cover NPPs and those that do not enroll them as credentialed providers. Most payers will cover NPP services, but they may not enroll them. In this situation, a practice would bill under a physician’s NPI and follow the billing guidelines in the payer’s provider manual. Commercial payers will follow state laws and often require modifiers to correctly identify the provider and supervising physician providing care.

More from mgma.com:
Know your state laws governing NPPs before you incorporate them in your practice
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Staffing the patient-centered medical home, PCMH program, April 21-23, Chicago

Technology — such as EHRs, online portals and mobile apps — can make it easier for patients to access your practice. But for many, phone calls are still the primary way patients communicate with you. There are ways to improve how you manage your practice’s phones to provide better patient care and save staff time:

Record your phone calls

Consider installing a call recording mechanism if your phone system doesn’t already have one.

Charlene Burgett, MS, CMA, CPC, CMSCS, MGMA-ACMPE member, and administrator, North Scottsdale [Ariz.] Family Medicine, uses her phone recording system to manage inconsistencies between staff and patients.

“I would find myself having to determine if the patient was telling the truth vs. my employee,” Burgett says. “Since most of the ‘he said-she said ’was in telephone conversations, I thought having the ability to record the calls was a necessity.”

If she finds that an employee gives the wrong information, such as billing or appointment information, or if he or she did not provide the best customer service to a patient, Burgett plays back the phone call to the employee.

“They listen and discover the problem themselves,” she says. “It makes my job easier when they have buy-in.”

Develop a metric system

One MGMA-ACMPE member developed a system to benchmark several phone metrics in an attempt to minimize patient hold time and make his front office more efficient.

Richard Lyon, MGMA-ACMPE member, executive director, Coastal Orthopaedics PC, Norwalk, Conn., purchased a new phone system that provides reports for various phone metrics:

Abandonment rate
Among those metrics is the abandonment rate – the percentage of callers who hang up before getting the chance to speak to someone. Lyon expects no more than eight to 10 abandoned calls per day, but he discovered that this number goes up on high-traffic days, such as Mondays and Fridays. A supervisor runs a daily report on the number of abandoned calls and has a front-office staff member call those people back.

Average hold time
Lyon benchmarks the average time a caller is left on hold after a staff member answers the phone. The group strives for one minute or less with the limit at no more than two minutes.

Average call time
Lyon’s practice aims for phone calls to last, on average, 1 minute and 45 seconds. Lyon adjusts this benchmark based on the type of call — address verification will take much less time than a patient with several questions —but he wants the call time for new patients making an appointment, in particular, to stay close that mark.

Move phones “off stage”

Dedicating certain staff members to only answer phones ensures that there is a dedicated, focused staff to manage the lines, which reduces delays and repeat calls, according to Elizabeth Woodcock, MBA, FACMPE, CPC; and Deborah Walker Keegan, PhD, FACMPE, in their new book, It’s Your Call: Mastering the Telephones in Your Medical Practice.

Woodcock and Walker Keegan recommend that telephone work should not be performed in front of patients who are arriving at or departing from the practice. Front-office staff members should either interact with patients face-to-face or over the phone — not both.

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While 2015 seems like a long way down the road, your participation this year in the PQRS program will affect whether or not eligible professionals (EPs) in your practice are penalized in the future. This is because the Centers for Medicare and Medicaid Services (CMS) finalized regulations that require the 2015 1.5 percent PQRS penalty to be based on 2013 PQRS quality reporting.

2013 is also a key year for the PQRS program in that it’s the second to last year in which EPs can earn an incentive payment of .5 percent for successful participation. PQRS participation in 2013 may also affect the impact of the value-based payment modifier (VBPM). Visit our policy pages for resources on quality reporting.

We know PQRS participation can be challenging, but EPs who are not yet participating should consider starting the process to avoid future penalties.

To get you started, we've provided answers to three common questions members ask the MGMA Government Affairs staff:

How do I get started in the PQRS program?

1. Providers must determine if they are eligible to participate
2. EPs should determine which reporting mechanism best fits their practices. PQRS has the following methods for reporting data to CMS:
   - Claims-based
   - Registry-based
   - Via a qualified EHR
   - Via the Group Practice Reporting Option (GPRO)

Each reporting option might have different reporting criteria and quality measures, which is why it’s important to review all applicable reporting options, data measures and specifications for each measure.

Collecting quality measures for certain reporting criteria might be simpler if your practice uses an EHR, says Laura Palmer, FACMPE, MGMA-ACMPE senior industry analyst. Some EHR templates may include quality measures, such as check boxes or required fields, which make it easier to pull reports for those measures.

“Specialty-specific EHR templates may already have fields built into their preventive/wellness or follow-up visit templates,” Palmer adds. “These help capture quality measures in the documentation.”

Individual EPs do not need to sign up or pre-register to participate in the program.

How do I avoid the 2015 PQRS penalty?

To avoid the penalty in 2015, EPs must meet criteria for satisfactorily reporting quality measures specified by CMS for 2013, and reporting criteria vary for individual EPs and those participating in the GPRO.

How are PQRS and the VBPM related?

The VBPM, a provision of the Patient Protection and Affordable Care Act, will use cost and quality data to adjust physician payments when compared with other EPs in the program. The modifier will be applied in 2015 to group practices of 100 or more EPs and is based on 2013 PQRS performance. Essentially, application of the VBPM is dependent upon satisfactorily reporting data on PQRS measures for 2013. Groups of 100 or more EPs in 2015 will be subject to a 1 percent penalty for unsatisfactory reporting or nonparticipation. The VBPM will apply to all EPs, regardless of group size, in 2017 and beyond.

The program’s nuances and frequent revisions can make the PQRS program challenging to navigate. Whether you’re a seasoned PQRS participant or 2013 will be your first year in the program, we encourage members to use our new Interactive PQRS Impact Assessment to help you understand participation requirements for the 2013 PQRS and VBPM programs.

Professionals, who recognize the limitations of traditional payer-provider-employer interactions, are redefining their relationships and breaking down silos that have historically prevented collaboration to improve patient care and reduce costs. Group practice professionals on the cutting edge of this change are exploring direct relationships with employers and negotiating differently, said payer, provider and employer representatives on the “Driving Forces and Future Directions” panel at the MGMA 2013 Financial Management and Payer Contracting Conference (FMPC) in Phoenix last month. And that concept was echoed by MGMA-ACMPE members throughout the three-day meeting.

The payer-provider-employer relationship

Panelists identified cost and quality as the main drivers of change in healthcare, and cited the need for access to high-quality, timely data to enact the type of transformation that will improve population health.

“The nature of our relationship has to change,” said Chris Lloyd, chief executive officer, MHMD, Memorial Hermann Physician Network, Houston, who spoke about data-driven decision-making that involves physicians, payers and healthcare purchasers. “Ideally we will be asking [these partners] whether we are doing the job right. These are the conversations that we have to have.”

These types of conversations — between physicians and employers or physicians and payers — are not common. But times are changing.

To illustrate that change, one attendee told the group about a positive experience she had going around an unresponsive third- party payer and directly to the company on behalf of its self-funded plan. She told the company that while the practice would like to treat its employees, the group was unable to do so without prompt payment.

“It does work,” said Lori-Ann Martell, LPN, CMPE, managing partner, Prēcis Medical Management, Naples, Fla. “We negotiated higher rates and carve-outs for evening hours by going directly to the employer.”

That practice may become more common as employers assert themselves as purchasers, said Erin O’Connor, practice leader, Cammack LaRherre Consulting, New York, a panelist, who hears mounting frustration from clients — employers of various sizes.

“Typically healthcare is the second most expensive line item on their budgets and they feel like they have no control over it,” O’Connor said. As a result, she hears clients say, “We don’t want to be in the benefits business anymore,” which she attributes to the “lack of control over that dollar spend.”

Data sharing

There are a few healthcare models, such as accountable care organizations, that offer more collaboration — and data sharing — between employers, providers and payers, said Kerri Balbone, national vice president, provider relations, United Healthcare, Cypress, Calif., panelist. “If you share information, it is a tangible way for people to act differently and see change. There’s a feeling of being in this together.”

Anders Gilberg, MGA, senior vice president, MGMA Government Affairs, acted as moderator and asked about the role of data in future relationships. “Whoever has the data has traditionally had the power in healthcare,” he said. “If you want success, you have to have data, down to the claims data.”

Lloyd agreed that access to timely data — on at least a monthly basis — is imperative to change the cost trajectory, and said “some payers are much more willing to share timely data, and I wouldn’t enter into a negotiation without getting that claims data.”

But it isn’t just claims data that matters. “It’s the data that physicians have that payers need,” Balbone explained. “We need a way to share it. I need aggregated clinical data that we can act on. I have the claims data, but I don’t have enough data about the clinical experience.”

O’Connor agreed, and noted that when payers, purchasers and providers mine and apply aggregated data, they can use business intelligence to measure outcomes and assess what really brings value in what she described as the new era of health management.

The discussion—between payers, providers and employers—continues at the 2013 Patient-Centered Medical Home Conference, April 21-23, in Chicago.

More from mgma.com:
Truly patient-centered care requires collaboration
4 important value-based reimbursement terms
7-point checklist to prepare for payer negotiations