2021 Washington Update - Matt Devino, MPH MGMA GOVERNMENT AFFAIRS
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2021 Washington Update
Matt Devino, MPH
Associate Director
MGMA G OVERNMENT A FFAIRS
WASHINGTON , DC
mdevino@mgma.org | 202.293.3450
©2021 MGMA. All rights reserved.
Agenda
• Regulatory Landscape
• Alternative Payment Models (APMs)
• Upcoming Surprise Billing Rule
• 21st Century Cures Act Rules
• HIPAA Proposed Rule
• COVID-19 Relief
• Provider Relief Fund
• Paycheck Protection Program
• CMS Accelerated and Advance Payment (AAP) Program
• Congressional Agenda for 2021
• Advocacy and Member Engagement
©2021 MGMA. All rights reserved. -2-
Regulatory Landscape
Alternative Payment Models (APMs)
©2021 MGMA. All rights reserved.
Advanced APMs in 2021
Advanced APM list Advanced APMs allow eligible clinicians to
Bundled Payments for Care Improvement Advanced (BPCI-A) become a qualified participant (QP) and receive
a 5% APM incentive payment and exclusion from
Comprehensive Care for Joint Replacement (CJR)*
MIPS.
Comprehensive ESRD Care (CEC) Model*
Comprehensive Primary Care Plus (CPC+)
Medicare Shared Savings Program (MSSP) ACOs Tracks 1+, 2, and 3*
MSSP Basic Track E and Enhanced Track Following year-end legislation, QP thresholds
Next Generation ACO* required to achieve APM benefits were frozen at
2020 levels through 2023.
Oncology Care Model (OCM)*
Maryland Total Cost of Care Model
(Care Redesign Program & Primary Care Program) To become a QP, a clinician must receive at least
Vermont Medicare ACO Initiative 50% of their Medicare Part B payments or see at
Primary Care First (PCF) Model least 35% of Medicare patients through an
New in Advanced APM entity at one of the determination
Direct Contracting (DC) Model Options
2021 periods (snapshots).
Kidney Care Choices (KCC) Model (implementation only)
*model timeline extended due to COVID-19
©2021 MGMA. All rights reserved. -4-
New APMs in 2021
Voluntary
PRIMARY CARE FIRST (PCF) APM*
PCF supports the delivery of advanced primary care and is
based on principles of CPC+. Practice participants will be
selected for one of two cohorts, each spanning five
performance years:
• Cohort 1 began January 2021
• Cohort 2 will begin January 2022 (applications now open)
Participation:
Must be in a “PCF region” | Minimum of 125 attributed beneficiaries | Primary
care services ≥70% of collective billing |Experience with VBP arrangements |
2015 CEHRT
Download the MGMA member-exclusive PCF resource
CMS is currently reviewing the Seriously Ill Population component, which will no longer begin April 1, 2021.
The Cohort 2 Request for Applications (RFA) is available through May 21, 2021.
©2021 MGMA. All rights reserved. -5-
New APMs in 2021
Voluntary
DIRECT CONTRACTING (DC) APM*
Direct Contracting offers two voluntary risk-sharing payment
options that use Population-based Payments (PBPs):
1. Professional offers the lower risk-sharing arrangement
(50% savings/losses)
2. Global has the highest risk-sharing arrangement (100%
savings/losses)
The Geographic option is back under review by the Biden
administration, and the application deadline has been removed.
Participation:
• CMS announced 53 Direct Contracting Entities (DCE) participating in the first
performance year that begin April 1, 2021.
• CMS also announced it will not be accepting new applications for a second
cohort beginning January 1, 2022. Entities that previously applied, were
accepted, and deferred participation will be permitted to begin in 2022.
©2021 MGMA. All rights reserved. -6-
New APMs in 2021
Mandatory
RADIATION ONCOLOGY (RO) APM*
The RO Model will make prospective, episode-based (bundled) payments in a site-neutral manner for covered radiotherapy (RT)
services furnished during a 90-day episode of care for the 16 included cancer types.
• Bundled payments will be split into two components – professional and technical – to allow for use of current claims systems.
• Model links payment to quality using reporting and performance on quality measures, clinical data reporting, and patient
experience.
• Model will qualify as an Advanced APM starting in 2022.
Participation:
CMS is requiring participation from RT providers and suppliers that furnish RT services within randomly
selected Core Based Statistical Areas (CBSAs). Participants will be physician group practices,
freestanding radiation therapy centers, or hospital outpatient departments.
Learn more about the RO model
Following congressional action, this mandatory APM will now go into effect January 1, 2022.
©2021 MGMA. All rights reserved. -7-
Regulatory Landscape
Other Federal Regulations
©2021 MGMA. All rights reserved.
Surprise Billing: No Surprises Act & Upcoming Regulations
The No Surprises Act was passed as part of the Consolidated Appropriations Act of 2021 in
December 2020. Regulations are expected in July.
Law Overview
Initial payment determined by plan (or denial notice) within 30 days from when
provider bills plan.
For services provided by a nonparticipating
provider at a participating
facility/nonparticipating emergency facility. If provider rejects payment from plan, open 30-day negotiation period begins.
Providers cannot bill beyond allowed cost-
sharing amount.
If no agreement reached, plan or provider has 4 days to notify other party (and
HHS) that they will initiate Independent Dispute Resolution (IDR) process.
• Advocacy Win: IDR entity cannot consider government payer rates. MGMA previously advocated
for this.
• Concerns: MGMA is concerned that HHS might issue guidance that would give more weight to
certain criteria. Congressional members wrote to HHS, Treasury, & Labor expressing these concerns
©2021 MGMA. All rights reserved. -9-Implementing the 21st Century Cures Act
ONC/CMS regulations implementing this federal legislation:
▪ Combat information blocking *compliance began April 5, 2021*
▪ Require hospitals to supply admission, discharge, and transfer
(ADT) feed to practices *compliance began May 1, 2021*
▪ Increase interoperability and accelerate data exchange between
health information networks
▪ Promote open, accessible APIs-application programming interfaces
(leveraging FHIR)
©2021 MGMA. All rights reserved. - 10 -Information Blocking: Key Provisions
❖ Information blocking defined as any action – or inaction – that is likely to interfere with, prevent, or
materially discourage access, exchange, or use of electronic health information (EHI).
❖ For the first two years (through October 22, 2022), medical groups must respond to a request to access,
exchange, or use EHI with, at a minimum, the data elements identified in the United States Core Data
for Interoperability (USCDI) Version 1.
❖ Per ONC, the information blocking rule is NOT a requirement to proactively make all EHI available
through patient portals, APIs, or other health information technology.
❖ For healthcare providers, a forthcoming enforcement rule from OIG is required to establish “appropriate
disincentives” to penalize information blocking actions.
Download MGMA’s Information Blocking Toolkit
©2021 MGMA. All rights reserved. - 11 -Information Blocking: The Eight Exceptions
From HHS Office of the National Coordinator for Health IT (ONC): https://www.healthit.gov/topic/information-blocking -
©2021 MGMA. All rights reserved. - 12 -HIPAA Proposed Rule: Modifications to the HIPAA Privacy Rule
This proposed rule, introduced by the Trump
administration and now under consideration
by the Biden administration, was published
Jan. 21, 2021. Comments on the proposal
were due May 6. The rule proposes to modify
the HIPAA Privacy Rule with the goal of
expanding individuals’ rights of access,
increasing permissible disclosures of
protected health information (PHI), and
removing barriers to care coordination and
case management.
©2021 MGMA. All rights reserved. - 13 -HIPAA Proposed Rule: Key Provisions
The rule proposes to modify the HIPAA Privacy Rule by:
▪ Increasing individuals’ rights to inspect their PHI in person, including taking photos and videos of their PHI
▪ Shortening covered entities’ required response time to access requests from 30 days to 15 calendar days (also
shortening the optional 30-day extension to 15 calendar days)
▪ Requiring providers to respond to oral requests to direct electronic PHI to a third party when the request is “clear,
conspicuous, and specific” (replacing current requirement that such requests be in writing and signed)
▪ Requiring providers to act on behalf of patients to obtain electronic copies of PHI in an EHR from one or more
other covered entities upon an individual’s request
▪ Amending the permissible fee structure for responding to requests to direct ePHI to a third party and clarifying
when ePHI must be provided to an individual free of charge
©2021 MGMA. All rights reserved. - 14 -HIPAA Proposed Rule: Key Provisions (continued)
▪ Requiring covered entities to post estimated fee schedules on their websites for access and for disclosures with
an individual’s valid authorization (upon request, provide individualized fee estimates and itemized bills)
▪ Reducing identity verification burden by prohibiting providers from imposing “unreasonable measures” on an
individual, including for personal health applications that an individual authorizes on their behalf
▪ Permitting covered entities to disclose PHI to social services and community-based organizations for
individual-level care coordination and case management without the individual’s explicit authorization
▪ Eliminating the requirement to obtain a written acknowledgement of receipt of a direct treatment provider’s
Notice of Privacy Practices (NPP)
▪ Modifying the content requirements of the NPP to clarify for individuals their rights with respect to their PHI and
how to exercise those rights
Given this proposed rule was issued by the previous administration, the likelihood that its provisions will
be finalized and timeline for publication of a final rule remains unclear.
©2021 MGMA. All rights reserved. - 15 -COVID-19 Relief
Provider Relief Fund
©2021 MGMA. All rights reserved.Provider Relief Fund: Announced Allocations to Date
Allocations in Billions
High-impact hospitals, $22.0
Safety net hospitals, $13.3
Phase 1: Medicare providers,
$50.0
Rural health clinics and General
hospitals, $11.3 Distributions,
$92.5
Phase 2: Medicaid/CHIP
SNFs, $9.4 providers, $18.0
Uninsured testing & treatment,
$1.7 Unallocated*, $25.9 Phase 3: Previously
Children's hospitals, $1.4 ineligibile providers, $24.5
IHS , $0.5
Total: $178 Billion
*Includes $3 Billion appropriated by The Consolidated Appropriations Act of 2021
©2021 MGMA. All rights reserved. - 17 -PRF: Reporting and Auditing Requirements
Providers Receiving >$10k Providers Expending >$750k in a year
Recipients that received one or more payments Due to longstanding regulations, any organization that
exceeding $10,000 in the aggregate from the PRF receives federal grant funding and expends more than
will be required to demonstrate compliance with the
$750,000 in federal dollars in any given year is required to
T&Cs, including use of funds for allowable undergo a single audit* to ensure compliance with the grant’s
purposes, for each PRF payment. rules and regulations. Funding issued under PRF is
catalogued as CFDA 93.498 Provider Relief Fund and CFDA
HHS published a Notice of Reporting Requirements, 21.019 Coronavirus Relief Fund.
including data elements to be collected in the
reporting process. The PRF Reporting Portal is *It is called a single audit because it is a standard used by all federal
currently open for registration only. agencies that covers financial statements and records, expenditures and
internal controls, as well as requirements specific to the grant itself. A
single audit reviews a targeted funding source for allowable costs incurred
within the allowable time period and proper reporting to HHS.
Download the MGMA PRF resource
©2021 MGMA. All rights reserved.PRF: Resources Checklist
HHS has been rolling out guidance and making announcements through its Provider Relief Fund landing page.
✓ Guidance includes FAQs, which have been consistently evolving since HHS began making payments to
providers.
Group practices with questions should call the Provider Relief hotline at (866) 569-3522.
✓ When calling, providers should have ready the last four digits of the recipient’s or applicant’s Tax Identification
Number (TIN) and the name of the recipient or applicant as it appears on the most recent tax filing.
Since delaying the opening of the Reporting Portal, HHS has yet to publish a revised reporting timeline.
✓ There is currently no deadline to complete registration via the online portal, but PRF recipients should continue to
monitor the Reporting Requirements and Auditing page for updates.
Within 90 days of receiving a payment, providers must sign an attestation confirming receipt of the funds and
agreeing to the conditions of payment. Access the attestation portal for more information.
✓ Providers must submit separate attestations for each payment received.
©2021 MGMA. All rights reserved. - 19 -COVID-19 Relief
Paycheck Protection Program (PPP)
©2021 MGMA. All rights reserved.Paycheck Protection Program: Overview
The Consolidated Appropriations Act of 2021, signed into law in December 2020, made further modifications to the
program, and the PPP Extension Act of 2021, signed into law in March 2021, extended the window for borrowers to
apply for first and second draw PPP loans through May 31, 2021, or until funding is exhausted. Per this recent
legislation, new PPP flexibilities include:
• 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.
Download the MGMA PPP resource
©2021 MGMA. All rights reserved. - 21 -PPP: Loan Forgiveness Guidance
The Borrower may elect a Covered Borrowers shall be eligible for
Borrowers should contact their lender
Period between 8 and 24 weeks. The forgiveness in an amount equal to the
to complete the correct forgiveness
SBA eliminated its previous definition sum of the eligible payroll and
form.
of “Alternative Payroll Covered nonpayroll costs incurred and
Period”. payments made during the covered
1. The standard application.
period.
2. An abbreviated application called
“Form EZ” for borrowers who meet at • Eligible nonpayroll costs cannot exceed
For each individual employee, the 40% of the total forgiveness amount.
least one of three conditions, and
total amount of cash compensation
3. A simpler application for recipients of eligible for forgiveness may not • If a borrower does not meet the
requirement that 60% of the loan be
$150,000 or less. exceed an annual salary of $100,000,
spent on payroll costs, the borrower is
as prorated for the Covered Period. still eligible for partial loan forgiveness.
Borrowers must apply for forgiveness within 10 months after the last day of their covered period to avoid interest accrual. At that point, any
unforgiven amount will be subject to a 1% interest rate.
Borrowers will need to report items like tax filings, bank statements, and payment receipts as part of the loan forgiveness process. While formal
reporting is otherwise not required, SBA retains the right to review and audit loans.
Visit the SBA PPP Website
Review the SBA’s PPP Loan Forgiveness FAQ
©2021 MGMA. All rights reserved. - 22 -COVID-19 Relief
CMS Accelerated and Advance Payment (AAP) Program
©2021 MGMA. All rights reserved.CMS Accelerated & Advance Payment (AAP) Program
• The CARES Act amended the existing AAP Program, giving successful applicants access to upfront loans based on historic
Medicare billing. While an important financial relief program, the original provisions included harsh repayment terms.
• Following MGMA advocacy urging improvements, Congress revised the repayment conditions of the AAP by:
✓ Postponing the recoupment of disbursed funds until 365 days after the advance payment has been issued to a
physician practice;
✓ Extending the repayment timeline so that the loan balance is not due until September 2022;
✓ Reducing the per-claim recoupment amount from 100 percent to 25 percent for the first 11 months and then 50 percent
of claims withheld for an additional six months; and
✓ Lowering the interest rate from 10.25 percent to 4 percent for loans not repaid in full by September 2022.
• Several more bills have been introduced to further delay the recoupment timeline or convert these loans into grants.
CMS announced that recoupment began as early as March 31, 2021. MACs will show the recoupment on the remittance
advices issued for Medicare Part A and B claims processed after the one-year anniversary of when the first loan
payment was issued. The recoupment will appear as an adjustment in the Provider-Level Balance section of the
remittance advice.
©2021 MGMA. All rights reserved. - 24 -Congressional Agenda for 2021 ©2021 MGMA. All rights reserved.
Healthcare Outlook in 2021
With the power shift in Washington following the recent election, we expect Congress to prioritize
these health care issues this year:
Healthcare Reform Drug Pricing COVID-19
With a new Congress and
new Administration, we This was a priority with COVID-19 continues to
are anticipating new bipartisan support prior to be the top healthcare
action to address COVID and will likely issue that has the federal
healthcare access and continue to demand government’s focus, and
protection of preexisting attention. this will continue this year.
conditions.
©2021 MGMA. All rights reserved.Sequestration and Medicare Payment
MGMA supports efforts to extend the 2% Medicare sequester moratorium
2% Medicare Sequester Cuts Delayed
Congress passed, and President Biden signed into law MGMA-supported legislation to extend the Medicare sequester
moratorium for through December 31, 2021.
4% PAYGO Sequester TBD
There is a projected 4% Medicare spending cut stemming from the American Rescue Plan from taking effect in FY 2022.
This automatic cut stems from the statutorily required Pay-As-You-Go (PAYGO) rules around reconciliation, the process by
which the COVID relief package was passed. A PAYGO sequester like this has never been triggered before, and Congress
has until the end of the year to prevent these cuts from taking effect.
MGMA.com/CONTACTCONGRESS
©2021 MGMA. All rights reserved. - 27 -Medicare Telehealth
MGMA supports important updates to Medicare telehealth post COVID-19
The Future of Telehealth
MGMA is urging Congress to:
1. Preserve the patient-physician relationship to promote high-quality care
2. Remove geographic and originating site restrictions
3. Allow permanent coverage of audio-only services
4. Reimburse telehealth visits equally to in-person visits
MGMA supports the CONNECT for Health Act, which was reintroduced this Congress. It would
remove the geographic and originating site restrictions permanently.
Read MGMA’s comments to House Ways & Means and Energy & Commerce Committees
Access MGMA’s grassroots letter here
MGMA.com/CONTACTCONGRESS
©2021 MGMA. All rights reserved. - 28 -Prior Authorization
MGMA supports important updates to improve and streamline prior authorization
Improving Seniors’ Timely Access to Care Act
• Require MA plans to support electronic prior authorization;
• Require MA plans to make real-time prior authorization decisions;
• Exempt perioperative services from prior authorizations; and
• Require MA plans to publicly reveal what services require a prior authorization, how many are approved, and how long
on average they take to approve.
This legislation enjoys bipartisan, bicameral support, and with MGMA support it has
been reintroduced by its sponsor in the new session of Congress!
helped write this bill!
MGMA.com/CONTACTCONGRESS
©2021 MGMA. All rights reserved. - 29 -Medicare PFS Conversion Factor/Budget Neutrality
MGMA strongly opposes cuts to Medicare reimbursement
Proposed 2022 Physician Fee Schedule (PFS) Conversion Factor TBD
• Background - $3 billion injected into PFS last Dec. for CY 2021 & three-year delay of G2211 until CY 2024
• Legislative solution is needed to prevent cuts again in CY 2022
• MGMA has asked for $3 billion to be put into the PFS as part of the forthcoming infrastructure package
• We will know more once the CY 2022 PFS proposed rule comes out in July
MGMA.com/CONTACTCONGRESS
©2021 MGMA. All rights reserved. - 30 -MGMA Advocacy and Member
Engagement
©2021 MGMA. All rights reserved.
- 31 -MGMA Advocacy During COVID-19 Pandemic ©2021 MGMA. All rights reserved. - 32 -
MGMA Advocacy in 2021
Outstanding Asks
❑ Extend telehealth flexibilities beyond expiration of the PHE
❑ Automatic MIPS hardships for 2021
❑ Eliminate 4% PAYGO reduction to Medicare payments in 2022
❑ Extend deadline to use PRF payments, distribute remaining funds, clarify and simplify reporting requirements
❑ Delay mandatory MSSP quality reporting changes set to take effect in 2022
❑ Extend Next Generation ACO model through the end of 2022
❑ Improve medical group participation in federal COVID-19 vaccine distribution plans
Read more in MGMA’s 2021 Advocacy Agenda
©2021 MGMA. All rights reserved. - 33 -MGMA.com/CONTACTCONGRESS ©2021 MGMA. All rights reserved. - 34 -
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©2021 MGMA. All rights reserved. - 35 -Resources from MGMA Government Affairs
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©2021 MGMA. All rights reserved. - 36 -Questions?
Matt Devino, MPH
Associate Director
MGMA G OVERNMENT A FFAIRS
WASHINGTON , DC
mdevino@mgma.org | 202.293.3450
@matt_devino
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