Medicare Finalizes 2023 Payment and Quality Reporting Changes

Originally published in the November 1, 2022, issue of MGMA’s MGMA Regulatory Alert
Reprinted with permission from MGMA

The Centers for Medicare & Medicaid Services (CMS) released the final 2023 Medicare Physician Fee Schedule (PFS) rule this afternoon, which in addition to major payment implications, includes changes to the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) participation options and requirements for 2023. The final rule:

  • Sets 2023 Medicare payment rates for physician services. For 2023, CMS finalized a conversion factor of $33.0607 and $20.6097 for Anesthesia (a decrease of -4.47% and -4.42%, respectively, over final 2022 rates);
  • Finalizes implementation of provisions of the Consolidated Appropriations Act, 2022 that extend the application of certain Medicare telehealth flexibilities for an additional 151 days after the end of the COVID-19 public health emergency (PHE), such as allowing telehealth services to be furnished to patients in their homes;
  • Extends flexibilities to permit split/shared E/M visits to be billed based on one of three components (history, exam, or medical decision making) or time until 2024;
  • Expands access to behavioral health by permitting marriage and family therapists, licensed professional counselors, and others to furnish behavioral health services under general supervision instead of direct;
  • Maintains the MIPS performance threshold at 75 points for the 2023 MIPS performance year/2025 payment year;
  • Adds five new MIPS Value Pathways related to nephrology, oncology, neurological conditions, and promoting wellness, for voluntary reporting beginning in 2023; and
  • Creates an advanced incentive payment pathway for certain low-revenue, new entrant accountable care organizations to bolster participation in the Medicare Shared Savings Program.

MGMA submitted detailed comments in response to the proposed rule in September. Be on the lookout for a more detailed analysis of the final changes to physician payment policies and the Quality Payment Program (QPP) in the coming weeks.

Additional information about the final rule is available in the PFS fact sheet and the QPP fact sheet.

August Lunch & Learn Webinar Recording

Strengthening the Provider-Payer Partnership from Onboarding to the Point of Care

Thank you to everyone who participated in our Lunch & Learn Webinar on August 16th. BCBSNC discussed how they are reimagining its partnership with the provider community through multiple initiatives that redesign the onboarding process to improve the provider experience and “meet care teams where they are” with actionable data, technology tools, and hands-on support to impact care outcomes. At the button below, you will find a link to the webinar video recording.

Follow this link to view the transcript of the webinar’s Q&A session.

Thank you again for participating. Watch your email and the website for more webinars coming soon.

Keys to Success in Value-based Care Systems

By Carlos Jackson, Ph.D. and Paul Mahoney, Community Care Physician Network

2022 Alliance sponsor feature article courtesy of Community Care of North Carolina

The movement to value-based payment systems occurring simultaneously with a pandemic and, in North Carolina, sweeping changes to Medicaid, has made for an incredibly challenging environment for medical practices, particularly independent practices. This new environment requires new workflows and new approaches to managing patient panels.

The good news is that, working together, independent practices can still thrive in this new environment. In supporting the more than 900 practices in the Community Care Physician Network (CCPN), we’ve identified four critical keys to success, highlighted in the graphic below. At CCPN we work with practices where they are, share best practices pioneered by similarly-situated practices and help them find practical solutions to daily challenges.

CCPN exists to help member practices thrive financially, provide high-value care, and enable providers and patients to maximize their satisfaction with the practice of medicine. CCPN is governed by practicing, community-based physicians.

We have found that for many practices, the most challenging piece of this puzzle is making the best use of data. Practices are awash in data, but can they parse it intelligently to pull out what is actionable, and identify the information critical to hitting the metrics that drive present and future revenue?

Click on image to enlarge

CCPN has made significant investments in tapping into the potential of EHR clinical data without practice staff needing to devote significant time in making sense of it all. Through new tools and innovative partnerships, we have built an infrastructure to help our network practices identify opportunities to close care gaps, improve quality and patient engagement and ultimately hit metrics that satisfy payer bonus arrangements, generating significant additional revenue critical to the long-term financial viability of the practice.

Practice PerfectSM Dashboard
Designed with busy practices in mind, Practice PerfectSM is a Tableau-based business intelligence tool that distills complex information from multiple data sources, identifying actions you can take right now to boost quality and improve performance. Recommended ActionsSM are an efficient and unique way of viewing worklists taking multiple patient and practice factors into account in order to help you prioritize long lists of care gaps.

The dashboard synthesizes claims, hospital visits, and individual risk scores to prioritize patient needs, as well analyzes the cost, utilization, and disease burden of a practice’s Medicaid patient panel. The dashboard also provides monitoring of performance on contract measures to inform practices of their progress on meeting contract measures. Users can quickly create targeted patient lists to determine where to best focus resources and improve performance. Additionally, Recommended ActionsSM integrate with clinical and scheduling data, as well as ADT and immunization feeds from outside vendors, for more actionable and up-to-date guidance. The dashboards are organized in a way to not overwhelm the provider and offer just enough information to help them be successful.

VirtualHealth™ Provider Portal
The VirtualHealthTM Provider Portal connects practices with their CCNC Care Management team – partners for improving patient outcomes. This provides secure access to Medicaid patient care management documentation, comprehensive needs assessments, and care plans. Through the portal, clinicians can make referrals to care management and enjoy secure communication with patient care teams. Clinicians can view patient history from claims, pharmacy, and hospital data – keeping them “in the know” regarding what care patients are receiving from outside their practices.

Value-based Informatics Program (VIPSM)
CCPN has significantly upgraded technology that supports practice success under value-based contracts across all payers and populations – at no additional cost to our CIN practices. We pull clinical data from practice EHRs to measure quality more easily. This greatly helps practices generate bonus payments from insurers. Our system also gathers appointment data to help practices better capitalize on Recommended ActionsSM. We alert practices to care gaps and opportunities to improve the accuracy of RAF scoring. We do this by joining EHR data with claims data for a more comprehensive view of patient care that yields improved insights. These tools also reduce administrative burden on practice staff. We are also piloting some in-line prompting tools that will provide practices with real-time alerts at the point of care. We believe that putting information in the hands of providers at the right time is one of the keys to success in value-based contracting.

While the environment for primary care practice won’t get easier anytime soon, help is available from your peers and CCNC. Together, we can help you find a path to financial strength and greater satisfaction with the practice of medicine for you, your staff, and your patients.

Click on image to enlarge

Community Care Physician Network (CCPN)
CCPN is a physician-led, clinically-integrated network that helps independent primary care physicians deliver high-quality, cost-effective care. CCPN priorities are helping practices thrive financially, provide high value care, maximize provider and patient satisfaction, and take charge of their own destiny.

CMS Publishes Surprise Billing State Enforcement Letters

Originally published in MGMA’s Washington Connection
Reprinted with permission from MGMA

The Centers for Medicare and Medicaid Services (CMS) has published a comprehensive list of state enforcement letters for the requirements under the No Surprises Act. These state letters, including letters to the District of Columbia and U.S. territories, outline CMS’ current understanding of which surprise billing requirements each state is enforcing and what requirements CMS will enforce.

The letters also outline whether the federal independent dispute resolution and patient-provider dispute resolution processes apply in each state, and under what circumstances. These state-specific letters will help providers determine what governing body oversees their surprise billing requirements. More information about surprise billing is available on the MGMA surprise billing landing page.

Medicare Telehealth Waivers

Updated March 1, 2022 Courtesy of MGMA

In 2020, the Department of Health & Human Services (HHS) instituted flexibilities that waived many of the generally applicable rules governing Medicare telehealth services in response to the COVID-19 pandemic. Many of these waivers are in effect through the duration of the COVID-19 public health emergency (PHE). Once the PHE concludes, many of these flexibilities will end without further congressional or regulatory action. The COVID-19 PHE is currently in effect through April 16, 2022. Please keep in mind that this resource addresses Medicare payment policy, and that Medicaid and commercial payers may institute their own payment rules.

2021 NCMGMA Impact Report

The More You Know, the More We Grow!
Take a look back at the 2020-2021 NCMGMA year

To increase the transparency of our organization, we proudly present to you the 2020-2021 NCMGMA Impact Report (PDF).

Inside you will find a letter from our 2020-2021 President, Amanda McKinney, and metrics from our various communications, programs and events from the past year. Our hope is this report gives you an idea of the association’s activity and health, and shows you all we are doing for our members and practice management in North Carolina.

Thank you to all of our members and sponsors for your continued support of NCMGMA. We look forward to another successful year in 2022, continuing our mission to be “the leaders for tomorrow’s healthcare.”

Improving Liquidity in Healthcare Risk

By Michael Kopko, CEO and Co-founder, Pearl Health

2021 Alliance Sponsor Feature Article Courtesy of Pearl Health

(Healthcare) Risk Is Opportunity

The slogan for the Society of Actuaries is “Risk is Opportunity.” As providers consider managing healthcare risk through value-based models, they will convert risk into opportunities for themselves—opportunities to increase and stabilize their revenue, be more financially aligned to their patients’ health outcomes and the good work they got into medicine for, and the more elusive advantages of being on the vanguard of important change.

To be successful, they will need tools and information systems designed to manage that risk in real time; but what will also become obvious is that the more liquid — or cost-free — we can make getting access to healthcare risk, the better off we all will be.

A Brief History of Healthcare Risk

In our early modern history, patients predominantly bore their own healthcare risk.

Prior to the creation of religious institutions that bore some of the healthcare risk of their flock, patients were fully exposed to the financial implications of managing their own health conditions. In the 1900s, the emergence of capitation models structured by physicians to support corporations started to formalize the risk of healthcare and quantify it. Large companies offered it as a productivity and safety benefit for their laborers, and physicians priced it. The emergence of the health insurance industry was mostly a tax advantaged way to provide compensation in the form of healthcare to workers and, with scale, do that fairly affordably.

Fast forward to today, we see a complex system with most of the risk borne by large insurance companies — or the taxpayer, in the case of government health programs. This system is no longer cost efficient, but it is massive due mostly to the simple fact that managing risk historically has been done better at scale vs. a decentralized or distributed paradigm.

Expanding Access, Equity & Affordability in Healthcare Calls for Distributed Healthcare Risk

Click to expand. Image Credit:

Centralized systems are inefficient: they’re slower and require greater reliance on monolithic actors than distributed systems.

As we continuously look to expand the access, equity, and affordability of the healthcare system, we will necessarily need to look to more efficient delivery systems. Josh Raskin from Nephron Research, a leading healthcare industry think tank, writes,

“The next era of healthcare will be defined by the trend of physician enablement. We see the management of health, with the physician at the center, as leading to the holy grail of healthcare: better outcomes, lower costs and higher patient and provider satisfaction.”

Josh Raskin, Nephron Research

This shift will see movement of risk from the centralized “big box retailer” of yesteryear to more distributed networks optimized to manage more localized, specific risk (think a single physician responsible for the outcomes of their own patient panel).

A catalyzing force toward this future is a new government model, Global and Professional Direct Contracting (GPDC), also known as “Direct Contracting“.

Not unlike government facilitation of other socially important markets like mortgages and credit, Direct Contracting brings resources, infrastructure and ultimately efficiency to managing healthcare risk and does that on the chassis of standardization and trust. As this standardization becomes more reliable and these types of structures proliferate, a large, liquid market emerges that supports investment in this critical policy area.

Supporting a Distributed Healthcare Delivery System through Primary Care

At Pearl, we see some tremendous opportunities in this transition.

We’re eager to help support a more distributed, mesh-networked healthcare delivery system through our platform—a system that is powered by primary care and allows for greater independence of providers. We see too many of our resources focused on beating the billing, authorization, and denials business of our current system and not enough on root cause analysis and patient need. This shift in focus will result in better quality and higher satisfaction on behalf of patients.

As more providers can participate in the first dollar in healthcare, we forecast that a democratization of access to healthcare risk will ensue. This will not only lead to more financial opportunity for primary care, but will also enable more clinical innovation as models that focus on special needs and situations emerge and can serve patients directly. With these changes a new world aligned around value versus expenditures will emerge.

Click table to expand.

More Primary Care Providers Bearing Risk in Healthcare = Positive Network Effects = More Overall Success in New Paradigm

As we add providers who can effectively bear risk in healthcare, a tremendous network potential will accumulate that ultimately enables more providers, payers, and consumers to adopt and succeed in this new paradigm. This will lead to greater comfort with providers bearing risk, a community of like-minded physicians who can cooperate in these models, focused on patient outcomes and the total cost of care.

We’ll also see primary care providers become more central in the value chain, helping manage complex cases and armed with the information and the authority to guide their patients throughout the system. Over time, this will mitigate unnecessary utilization, whether ER admissions, avoidable surgeries or preventable in-patient care.

Click image to expand.

At Pearl, we’re focused on — and somewhat obsessed with — getting these primary elements working together at increasing speeds and expanding scale. It’s a simple flywheel that starts with providers (or doctors) as our core element. We assist them in participating in risk-based models by providing them data, technology, and support.

As we gain additional providers to Pearl’s model, we expand our network of enabled providers who can cooperate in a value-based network. This enables us to invite more payers to our model who can then offer more risk based models for our physicians. We start with Medicare but, as our network expands and our doctors perform, we can enter different lines of business.

This all combines to create a simple outcome: reducing the cost of accessing healthcare risk and improving liquidity of the system. It breathes oxygen into a financially broken system and implies a structure that pushes toward efficiency and savings instead of volume and expenditures.

For more insights like these, sign up for our newsletter, or follow us on LinkedIn or Twitter.

Direct Contracting Model Strategies that Drive Innovative Healthcare

2021 Alliance sponsor feature article courtesy of Pearl Health

It’s no secret that the U.S. healthcare system could benefit from a healthy dose of creativity and innovation. Over the past several decades, healthcare costs have been rising at an unsustainable rate, while patient outcomes have been less than ideal. Efforts to create a more value-based healthcare system, which have featured an especially concerted effort over the last decade, have thus far not succeeded. In recognition of this reality, the Centers for Medicare/Medicaid Services (CMS) has recently introduced its Direct Contracting model. Specifically designed to encourage innovative healthcare ideas, Direct Contracting will hopefully lead us toward a more value-based healthcare system.

Many healthcare organizations and providers believe the Direct Contracting model has tremendous potential. While the model is currently being used only for Medicare beneficiaries, many hope that its central themes–provider capitation, quality measures with minimal administrative overhead for practices, and global risk sharing–may soon be adopted by private payers and providers furnishing care in the commercial sector. Such proliferation will depend on the model’s initial success in managing costs of the Medicare population and how well providers adapt. If the model works as planned, it will incentivize innovative healthcare strategies, leading to better outcomes and lower costs. With this in mind, it’s essential that healthcare professionals understand ways to innovate in this environment.

Innovative Healthcare Strategy #1 – Enhance Workflow Efficiencies

It is well known that many healthcare systems lack efficient operational workflows. This is especially true in coordinating care among different care settings in and out of various facilities. Therefore, innovative healthcare ideas are needed to streamline many of these more complex care activities. The Direct Contracting model accomplishes this by linking rewards to value-based outcomes. As a result, all stakeholders are motivated to develop more efficient and coordinated processes of care. Healthcare organizations can leverage the Direct Contracting model’s investment capital construct (i.e. the ‘enhanced cap’) to pursue better workflow efficiencies. Likewise, they can encourage the use of standardized workflows that are patient-centric in an effort to reduce care variations. Similar to Lean Six Sigma approaches, these efforts reduce waste while improving the capacity for predictable and reproducible results. This is an area of innovation needed for many healthcare systems today.

Innovative Healthcare Strategy #2 – Advance Digital Integrations

Advancing and streamlining digital integrations across the healthcare system may lead to more efficient healthcare delivery. Interoperability, the ability of different digital healthcare platforms to communicate, has been a barrier for efficient and effective healthcare. Healthcare systems can use the Direct Contracting model to encourage improved connectivity and interoperability by incentivizing such investment through outcomes alignment. This inherently reduces waste by limiting duplication services and increases access to information for better decision-making. Such connectivity can also improve the insight of analytics efforts, providing healthcare systems with better data to drive future changes. By investing in these types of activities, organizations can better thrive under the Direct Contracting model and reap the rewards.

Innovative Healthcare Strategy #3 – Effective Provider Incentives

Under CMS’s Direct Contracting model, Direct Contracting Entities (DCEs) have the ability to structure bespoke risk contracts with the providers that they engage. A DCE may choose different risk tracks, taking on 50% or 100% of the risk and shared savings benefits. While past ACO programs allowed for similar risk-sharing, DCEs are afforded greater freedom to create more targeted risk-based and capitated contracts with providers that incentivize them to develop innovative healthcare solutions. This is one of the major advantages of the Direct Contracting model that did not exist with prior CMS approaches to value-based healthcare.

Innovative Healthcare Strategy #4 – Engage and Involve Patients

The Direct Contracting model places the burden to develop innovative healthcare solutions on DCEs and member providers. Yet the involvement of patients is critical to the success of efforts to achieve performance improvement in value-based care. By empowering and incentivizing patients to engage in this manner, DCEs can make better, more informed choices about which strategies they will invest in and patients can contribute to self-care and self-monitoring. DCEs and providers should therefore invest resources in educating and training patients in these areas. In doing so, they are better able to utilize patient resources that reduce costs and lead to better results. These types of activities also broaden care coordination across additional care settings that include the patient’s home environments.

Embracing a Culture of Innovation in Healthcare

Each of the above strategies can help organizations and providers realize more innovative healthcare practices. The Direct Contracting model simply serves as a framework by which these efforts can be used. Over time, however, DCEs and providers alike can embrace a culture of value-based innovation to achieve healthcare goals.

1. Adams, K. (2021). 6 big ideas in healthcare innovation. Becker Hospital Review. Retrieved from

2. Ibid.

3. Ibid.

4. Ibid.

Update on AmeriHealth Caritas EFT Deadline

AmeriHealth Caritas EFT Enrollment Deadline Extended to December 1

AmeriHealth Caritas North Carolina uses ECHO Health Inc, a partner of Change Healthcare, for electronic payment processing. There are no fees to receive a direct payment from AmeriHealth Caritas North Carolina via EFT or to receive an Electronic Remittance Advice (ERA).

All providers must enroll in EFT. To enroll in EFT with ECHO Health, providers must have received a payment via ECHO. To support providers in registering, AmeriHealth Caritas North Carolina is issuing paper checks and providing a direct link to providers to enroll in EFT for their AmeriHealth Caritas North Carolina payments. Please use the information on the Remittance Advice and the check stub to enroll in EFT. To enroll please visit

Providers who are already enrolled in ECHO for payments from other payers may have agreed to an all payor fee. They can choose to get direct payments for AmeriHealth Caritas North Carolina with no associated vendor fees by calling ECHO Health at 888-834-3511.

After December 1, providers that have not enrolled in EFT will be paid via virtual credit card (VCC). There is a fee charged by the card merchant for VCC payments.

If you have concerns, please contact Peggy Vickery, Interim Director of Provider Network Management, at 843-569-4630 or contact your dedicated ACNC account executive.

June 22nd Lunch & Learn Webinar: Top 10 Payer Contracting Tools

Top 10 Payer Contracting Tools: 2021 and Beyond

Tuesday, June 22nd | 12:00 PM – 1:00 PM EDT | Zoom

This presentation focuses on supporting practices on the payer contracting journey by defining a step-by-step process to build an effective strategy through sharing the top 10 tools used by successful practices. Registrants will receive top 10 payer contracting tools as take-aways and will include:

  • Value proposition template
  • Payer contract termination evaluation tool
  • Payer relationship check list
  • Payer contracting preparation grid
  • Contract catalogue template
  • Transparency grid by provider
  • Proposal determination tool
  • Hassle factor matrix
  • Action plan template
  • Contract Quick Reference Guide tool

The talk concludes with recommended go-forward strategies to integrate the contracting process into your core financial management strategy.

Webinar Speaker

Doral Davis-Jacobsen, MBA, FACMPE
Partner at Prosper Beyond LLC

Doral Davis-Jacobsen, MBA, FACMPE, is a Partner at Prosper Beyond LLC, a specialized healthcare consulting firm nestled in beautiful Asheville, North Carolina. Doral is a seasoned healthcare consultant with over 20 years of experience serving healthcare providers ranging from solo practitioners to large academic medical centers. Doral serves as the Chair for the North Carolina MGMA Payer Contracting Committee. Doral is a co-author of MGMA’s book, Transitioning to Alternative Payment Models: A Guide to Next Generation Managed Care Contracting, published in October 2016.


This webinar is free but you must be registered to attend. Space is limited so register early! After you register, you will receive an email confirmation and an email reminder with webinar login instructions.

Continuing education credit may be granted through your professional organization (MGMA, PAHCOM, AHIMA, etc.). Please self-submit for these organizations.


For questions, please contact the NCMGMA offices at