June, 2017:

Deconstructing the Construction of a New Facility

The success of building a new clinical location is dependent on many factors and people working collaboratively and in sync.  Some tips for a successful outcome include:

Time – One can never start planning too early.  Prior to construction and during construction, take time to understand and document wants vs. needs vs. must haves.  You can narrow and prioritize the list at a later date.  Changes to the design during construction can result in additional costs.

People – Consult the users of the space.  This includes all stakeholders including providers, front desk, billing, clinical staff, ancillary services and your administrative team.  Observe the work in the current space and verify all of the key workflows.  Ensure barriers to productivity are resolved.  As you design the new space, consider opportunities to enhance efficiency, patient and staff and physician satisfaction.

Communication – Consider building “touchdown space” in the clinical area and optimize your flow.  Many designs now have co-located shared space with providers and support staff, which is known to improve communication and teamwork.

Voice of the Patient – The voice of the patient is key when constructing and problem solving; not to mention when creating a patient centered environment.  Interview patients to obtain their input.  Consider surveys, on-site interviews, focus groups and outreach calls to gather information.

Practice – Test out the new workflows and create a mock-up of the exam room.  Map out your table, stools, cabinets, sharps boxes, locations for disposable supplies such as gloves, door, curtain, etc. Simulate how the team members and patients will move within the space.  A fun and effective exercise in the initial planning stage is to put together a cross functional team to create the ideal layout using post-its!  This helps to surface workflows but can also point out differences in opinion among the team.

Team Meetings – Consider if you will need space for teaching or team meetings.  With the implementation of value-based care, a shared administrative space may prove to be essential for your PCMH.  Don’t forget about staff meetings or educational programming, which is required by licensure or recommended by leadership.  If you are a teaching program, consider the needs of students, fellows, residents and instructors.

Technology – Consider your current level of technology.  Will the construction include new features of your current software or upgrades or a completely new system?  This is a good time to review your Electronic Health Record (EHR) and Practice Management System (PM) or Radiology PACS, and identify change opportunities to allow time to plan.  For example, my current client is using it as a vehicle to redesign and optimize their clinical capabilities.  Instead of assigning each student a designated workspace (i.e., Exam rooms 1 and 2), they are using the rooms as resources, which will allow for other users to utilize the exam room when the Monday and Wednesday provider is on vacation.  This change will allow a 36% opportunity to increase production.

Construction is exciting, but identifying a lead project manager can be essential to a successful outcome.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

CMS Quality Payment Program – APM Path- part 3 of a 3 part Series on MACRA

What is an Alternative Payment Model (APM)?

In part two of this specific blog series on MACRA, I emphasized the CMS QPP decision tree and covered the MIPS path.  In part three, we will discuss the APM path.

Alternative Payment Models (APMs) are new approaches to paying for care through Medicare that incentivize quality and value.  The CMS Innovation Center develops new payment and service delivery models.  Additionally, Congress has defined—both through the Affordable Care Act and other legislation—a number of demonstrations that CMS conducts.

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants: the Payment Amount threshold or the Patient Count threshold

Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.




  • A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care.
  • Can apply to a specific condition, care episode or population.
  • May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs.


Advanced Alternative Payment Models (AAPMs)

Advanced APMs are a subset of APMs and enable practices to earn more rewards for taking on some risk related to patients’ outcomes and cost of care

Under the Quality Payment Program, clinicians who participate to a sufficient degree in Advanced APMs are excluded from MIPS and earn a 5% lump sum incentive payment based on their Part B professional services for a given year, and also receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs must meet the following three requirements:

  1. At least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other healthcare professionals.
  2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category.
  3. Be a Medical Home Model expanded under CMS Innovation Center authority or:
    1. Meet a revenue-based standard of financial risk that averages at least 8% of revenues at-risk for participating APMs
    2. Meet a benchmark-based standard of financial risk in which the maximum possible loss must be at least 3% of the spending target

In 2017, the following models are Advanced APMs:

  • Comprehensive ESRD Care (CEC) – Two-sided Risk Arrangements
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) – Two-sided Risk Arrangement

In future performance years, we anticipate that the following models will be Advanced APMs:

  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
  • New Voluntary Bundled Payment Model
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • ACO Track 1+

Under the AAPM path, clinicians will receive an annual 5% lump-sum bonus between 2019 and 2024, with a 0.75% increase to their Medicare physician fee schedule beginning in 2026.  While the AAPM track does not carry the penalty risks present in the MIPS track, APM entities must have a risk-based payment model for clinicians to qualify for AAPM.

While Advanced APMs have a fixed bonus incentive of 5% through 2024, it is important to understand that the Quality Payment Program does not change the design of any particular APM.  Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

How Do Eligible Clinicians Become a Qualifying APM Participant (QP)?

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants.  CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods:

  1. The Payment Amount threshold and the Patient Count threshold.
  2. Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.

Using the Patient Count Method, APM entities must see a minimum percentage of Medicare patients through the APM each performance year, with the percentage rising through 2022.

  • Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM.
  • CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity.
  • The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.
  • The QP Performance Period for each payment year will be from January 1—August 31 of the calendar year that is two years prior to the payment year.

Beginning in 2021, this threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.









What is a Partial Qualifying APM?

Clinicians are considered Partial Qualifying APM participants if their APM entities participate in an Advanced APM, but meet a slightly lower threshold outlined by CMS.

Clinicians participating in the Partial Qualifying APM track will not receive AAPM’s 5% incentive payment, but they can opt into the MIPS path if they can meet its reporting requirements.

In Summary

The shift from the Sustainable Growth Rate formula’s “fee-for-service” payment model to MACRA’s value-based payment model should ultimately help to preserve Medicare funds in the long-term while incentivizing ongoing initiatives that could make a positive impact on population health in the U.S.  The Advanced APM track and the QP status may be desirable for many MIPS eligible providers.  Due to the inherent financial risks involved in any AAPM, an organization should evaluate these programs with care and consideration.



Senior Consultant -Culbert Healthcare Solutions

Admissions/Registration: Helping to Improve Accounts Receivable

One of the most important ways to improve A/R is the admissions/registration areas of any healthcare organization.

Many facilities band-aid issues within the admission/registration areas by correcting errors in billings, which is not effective nor is it cost efficient.  It is estimated that it costs healthcare facilities $15 per visit to track and collect co-payments and deductibles after the fact.  For many healthcare organizations, such as physician offices, this practice could result in a zero net revenue gain.  Additionally, it costs healthcare facilities approximately $15 – $25 per visit for billing staff to correct registration errors and approximately $15 per statement sent to patients for co-pays, deductibles and co-insurances that could have been collected upfront.

So what steps can a healthcare facility take to remove the admissions/registration area band -aids and ultimately improve their A/R?

Step 1:  Management should be open to change

Most admission/registration managers have vast experience in their field and want nothing but a well-run department.  However, for many managers the stress of running a high-volume department that can potentially be open 24 hours a day does not allow them the luxury of thinking outside the box.  Staff may not be willing to discuss issues with management, some applications do not provide error reports to managers, and some applications do not record who made the error(s) so they cannot be addressed with that individual.  For improvement and changes within the admission/registration areas, management must be open to change, permit their staff to assist in recognizing issues and require their application(s) or MIS department to provide error reports.

Step 2:  Assign an impartial third party

The first step in this process is to assign the task of meeting with the admission/registration areas to an impartial third party.  This is the most important step in this process as admissions/registration needs to feel comfortable in discussing all issues they face daily without fear of retribution or criticism.  The impartial third party should not only meet with management of these areas, but with 75% of the staff covering all shifts.

 Step Three:  Logging issues

This is not the time to address or correct issues that are discovered.  Although issues presented need to be clear and concise, they should not be demonstrated or dissected as this is purely a fact finding process.  All issues discussed are to be logged no matter how insufficient they may appear.

Step Four:  Organization

Issues need to be organized into categories such as process, system, staffing, training and education.  Once this is accomplished a meeting should be held with management to determine what issues are the priorities and can be addressed immediately versus issues that may take time to resolve (such as lack of staff).

Step Five:  Resolving issues

Process issues:  It is imperative that management and staff be open to resolving processing issues.  A process should not be kept in place because it has “always been done this way” but because it enhances the admission/registration process.  An impartial third party can assist management in looking at the processes, determining if they are assisting or hindering the workflow and changing what does not work.

System issues:  Are the admission/registration pathways specific to your site or are they generic?  Does the application provide “help” screens or pathways that are easy to maneuver and are they specific to your site?  Are required billing fields designated as “must enter” and won’t allow staff to bypass?  Is your IT staff knowledgeable of your environment and application?  Is your application vendor directly involved with improving your application pathways?  Can your staff search for a patient’s prior admission/visits within the application?

Staffing:  Are the errors the result of under or overstaffing?  Both can be issues for admission/registration areas as too much work per staff member can cause a hurried approach whereas too many staff can cause disruptions in daily work.  When are most of your admissions/registrations?  Can your facility add or deduct staff according to daily needs?  Are pre-admissions/registration the practice of your department so that most of the information can be input prior to the patient’s visit?

Training:  Has your staff been properly trained in the workflows of the department and admission/registration pathways within the application?  Does staff understand what fields are required and why?  Does your staff update prior admission/registration information or just process the data?

Education:  Correction of errors must be done by the admission staff and not billing.  This is very important because they need to understand what constitutes an error and why.  Some applications only record the last person who worked on the admission/registration versus who made the error.  This limitation should not stop management from requiring error correction.  Although the last person who touched the admission/registration may not have made the error it is the responsibility of anyone who touches the admission/registration to ensure all information is correct.

Holding registration responsible for errors is a proven tool that will assist staff in knowing what an error is, assist management in recognizing what staff training needs are and allows billing to concentrate on their job responsibilities.  As registration is made aware of their errors, it is imperative to teach them how to perform registrations and keep them from repeating the same errors over and over.  Correction of their own errors will assist in staff in adhering to policy, train them in proper registration processes, and will ultimately decrease billing errors and free up billing to perform their job responsibilities.

Leverage MACRA to Support Long-Term Strategic Goals

Link here http://bit.ly/2sPdKAG

Catching Up At C-Live

GE Healthcare’s annual C-Live conference is always an excellent opportunity to catch up with our clients and colleagues, but most importantly it’s the time to find out what’s new with GE.  This year did not disappoint.  GE has shown that they are continuing to invest in their tried and true Centricity Business suite of products.  Their newest 6.1 version is packed with critical enhancement to improve patient access and revenue cycle workflows from Anesthesia billing enhancements to simple tools to improve the everyday tasks like dictionary exports.  GE continues to roll out new ETM workflows for all their modules from HPA to SIU interface edit lists.

Perhaps the most exciting part of the conference was watching some of our client partners present on how they have made the most of their existing GE systems.  Our clients are seeing some very impressive results, including:

  • Charge capture and TES optimization resulting in a $3M annual increase in cash collections
  • FSC Consolidation including an 80% reduction in the number of FSCs
  • Visit Type Consolidation & Standardization driving a 25% increase in appointment availability
  • GECB deployment to newly acquired medical groups covering 1,600 providers in 14 months
  • ETM Optimization resulting in a 2% reduction in A/R


Culbert looks forward to working with our clients as they implement this new version and tools into their processes.  We hope to see everyone at C-Live 2018 in Las Vegas!

CMS Quality Payment Program – MIPS Path

As we mentioned in our previous MACRA blog, the CMS Quality Payment Program (QPP) provides a choice of two paths for Medicare reimbursement:

  1. Merit-based Incentive Payment Systems (MIPS);
  2. Advanced Alternative Payment Model (AAPM); or the Partial Qualifying APM.

We will review the AAPM methodology in the next blog series.

Organizations that wish to participate in 2017 have until October 2 to make the difficult decision of which path to choose.  However, they must be able to submit their performance data by March 31, 2018.  The first payment adjustments will go into effect on January 1, 2019.

It’s estimated that about 90% of clinicians will participate in traditional Medicare through the MIPS track, which carries a greater possibility for both reward and penalty than the AAPM and Partial Qualifying APM paths.

Decision Tree for CMS QPP


MIPS was created by the Medicare Access and CHIP Re-authorization Act of 2015 to streamline multiple value-based programs including Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM).


Medicare Part B clinicians billing more than $30,000 a year AND providing care for more than 100 Medicare patients a year.


  • Physicians
  • Physician Assistants
  • Nurse Practitioner
  • Clinical Nurse Specialist
  • Certified Registered Nurse Anesthetists

Non-patient facing clinicians are eligible to participate in MIPS as long as they exceed the low-volume threshold, are not newly enrolled, and are not a Qualifying APM Participant (QP) or Partial QP that elects not to report data to MIPS.


  • Qualifying APM participant
  • Partial qualifying APM participant
  • Doesn’t meet the low volume threshold
  • Newly enrolled in Medicare (exempt until following performance year)


Pick Your Pace for Participation for the Transition Year

You have several options to determine how you will participate.  If you don’t submit anything to CMS for the 2017 performance period, you will receive a negative payment adjustment.  CMS is trying to make it really easy so that will not happen, hence Pick Your Pace.

Your choices are that you can:

Participate in an Advanced Alternate-Payment Model.

Choose to Test, which means you submit a minimum amount of data to avoid a downward adjustment in 2019.  So, what amount of data do you need to send?  That would be one quality measure, one Improvement Activity. or the required 4 or 5 required base scores of the Advancing Care Information Measures category.

You can participate for a partial year by submitting 90 days of 2017 data to CMS and you may earn a positive payment adjustment. So if you’re not ready on January 1, you can start anytime between January 1 and October 2, 2017.  Therefore, October 2nd is the last day that you can begin to collect your data and still have a full 90 days within calendar year 2017.

Full Participation: Submit a full year of 2017 data to CMS.  That also means that you would submit six quality measures, improvement activities that are either four medium-weighted or two high-weighted improvement activities, and either four or five Advancing Care Information measures.  Clinicians should pick what’s best for their practice.

Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment.

Every MIPS Point Counts

(EPs) will be measured annually in the four performance categories (Cost/Resource use, Clinical practice improvement, Quality &Advancing Care) to derive a MIPS score between 0 and 100.  That score will determine positive, neutral, or negative adjustments to each provider’s annual Medicare reimbursement.

CMS will set a performance threshold score each year that equals the mean or median of all EPs’ MIPS scores from a prior period.

Calculating the Final Score Under MIPS for Transition Year 2017

Under MIPS, if clinicians participate as a group, they are assessed as a group across all four MIPS performance categories since . A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site.

Providers’ scores will be publicly available to consumers via the Centers for Medicare & Medicaid Services (CMS) Physician Compare website.

Bonus Payments and Reporting Periods

MIPS, like many other pay-for-performance programs, uses retrospective data.  For example, MIPS uses data collected during 2017 to determine potential payment adjustments in 2019.  Positive adjustments are based on the performance data information submitted, not the amount of information or length of time submitted.

A full year gives you the most measures to pick from, BUT if you report for 90 days, you could still earn the max adjustment.  The best way to earn the largest payment adjustment is to submit data on all MIPS performance categories.  This option prepares you the most for the future of the program.

We’re encouraging clinicians to pick what’s best for their practice.

Source: https://qpp.cms.gov/

CMS Quality Payment Program MIPS graphics

Senior Consultant -Culbert Healthcare Solutions