We kind of shared a little bit, so I'm looking at things a little bit different as an administrator because I have faculty that I, you know, have to make sure that they do their faculty duties and teaching, but because part of their salary is also clinical revenue, it's a double-edged sword, whereas we know education and financials always is batting, fighting with each other. So what I found here is several issues that we need to be aware of. So first of all, this slide is Einstein saying question everything. So I think Jill kind of pretty much stated, you know, point blank, you better know what's going on, because especially if you're in academics or in a big group, somebody, usually an administrator, is submitting that stuff for you. And having been an administrator and being on a system, there are things that are done that you're not aware of because the incentive for an administrator is margin at the end of the year. And so things will be done, whether intentionally or unintentionally, to make the bottom line look better. And that can be done with, you know, this kind of program. And what that leads to is that you, the provider, are at risk for either fraud or abuse. So the difference is that, you know, one, you're doing it intentionally, the one, you're not, but ignorance is not an excuse. So when you look at the penalties, you can be excluded from Medicare and Medicaid for two years, which basically will destroy your career. You can also go to jail. And you also will have to pay back that money plus penalties. And depending on what the penalty is, it could be way above what you actually received incorrectly. The second thing, and there's actually a white paper if you go to the American Hospital Association that talks about some of the legal risk that this payment program can lead to. Because there's a push that if we're trying to improve quality, there's going to be collaboration between other groups of physicians. So for example, pelvic floor, you know, you're going to want to talk to and work with GIs, physiologists, physical therapists, et cetera, et cetera. The way the Stark Law and the anti-kickback laws are set up, it actually puts us at risk of breaking those because they're already hard to deal with. But then when you start talking with other physicians, we're actually put at a little bit of a negative because there's, as opposed to anywhere other business where they can talk business, we can't. So you need to be aware that when you talk to however you guys are going to report this and set up your programs that I always recommend having legal there. The other reason you should care is that this is what puts food on your table. So I saw, you know, the Kraft macaroni and cheese and it truly is going to be the program. And again, Sarah and I talked about is what Medicare does, Medicaid and commercial follows. Specifics, you know, Jill talked about you're being tracked by your tax identification number, you're being tracked by your NPI. So what you need to understand is that when you sit down and you have to be involved in the decision, you can't have somebody make the decision for you. There's pros and cons. So as a group, the pros are there's less work, you focus on the same measures as a group. You're going to kind of bring this into your culture, your workflow that these things automatically get collected. And in a group, you got your good quality numbers people and you're going to have your not so good quality numbers people. So it's going to balance your group out. But then the reverse of that is that you got those low performers. As an individual, you have more of a capability because the point, the main point here is maximize your score. You pick the highest metrics so you get the highest score, but it's going to take a lot more work and you will have to do it in some manner. You also have to know that things change and we all practice differently. So we may have work in two groups. So I actually may work for the university and cover the residents, but I also may have my own side private practice. So if you have that situation, it's advantageous to you because they'll pick your highest score. You're actually going to have two scores. So highest one counts. If you switch groups midway through a billing year, whichever score you had with each group, highest one wins. And then you also, especially if you're involved with faculty covering FQHCs or critical access hospitals, you need to know that if you bill, you have to report it as part of your metrics. If they bill, so the FQHC does the billing, then you don't have to worry about it. Just to kind of give you an idea of how this would affect the average urogynecology practice, the median revenue, this is not charges, is $540,000. I just took a 50% number of Medicare patients, so it's $217,000. So if you took a hit in 2019 and you just got the 4% decrease, you'd get a decreased payments of about $9,000 with all things being the same. As the penalty maximizes, you're going to have a $20,000 hit if you had the 9% decrease. So just understand that in a general urogynecology practice, 57% of your expenses take away your revenue and 32% of practices report that the next year their expenses went up. So the point is that if your revenue goes down because you take the hit and your expenses go up, which they do, rent, blah, blah, blah, blah, blah, you're going to have to get rid of something. And when I looked at it from my P&L statement, that basically would be one of my medical assistance. Yes, Jill. So Bob, are those numbers per clinician or per practice? Per clinician. No. Yeah. Yeah. This is the... So if you are a practice of 10 clinicians, let's say, so given these numbers, well actually not 10 clinicians, 10 eligible clinicians, you'd be looking at $90,000 at risk. Correct. Correct. That's a big hit. So like I said, I was down to pens and paperclips and pencils. So it would be getting rid of one MA. Jill brought this up. I just wanted to highlight it more. So this year, they increased the budget by 2%. Last year, the CMS budget for Medicare went up by 9% and the year before that, it was like 7%. So what's going to happen is that the increase between 2015 and 2019 is 0.5%, but then they're going to hold 2020 on as that amount of money. But I showed you the slide that the number of people aging or increasing. So a lot of the stuff, I think it's MedPAC that decides what the RVU dollars, just from what Jill was talking about, I think the RVU number is going to drop because they're going to have to figure out how to balance it. If you guys remember, that's what happened with Eurodynamics, it dropped, I think, 50%, right? Right. So CMS actually gets to decide the conversion factor. So they do take advice from MedPAC, but they calculate it based on a methodology that includes all Medicare policy. So changes in RVUs, changes in other sorts of payment policy, CMS payment rules that they've made, and then volume. So if volume increases, the conversion factor has to be neutralized, they call it budget neutrality, to bring it back to the amount of money available. And volume can be RVUs, volume can be dollars, volume can be people. If the amount of Medicare money spent either goes up or down by $20 million in a given year, by law, the Medicare program is required to recalculate the conversion factor. So as you can imagine, $20 million is not much in the big numbers that Bob mentioned earlier. So we do have to be cognizant of the fact that the 3588 number that we showed earlier will know in July, potentially CMS will propose what that number will be for 18. So your penalties and bonuses will vacillate depending on what that number is and how many RVUs you do in a given year. You can actually go to CMS's website and see how they do the budget for Medicare. The other thing that I just learned is that they can also play with the deductible that you have. And it's already a graduated deductible based on how much money you make after you're 65. So I think it starts tapering off at, what, $65,000, $100,000? Right. So the amount of deductible and the amount of premium that a Medicare beneficiary pays per year is recalculated by Congress and by the Medicare program and the Medicare trustees. And then that will also affect when the patient will have to get into the 80-20 versus paying their deductible first, et cetera. So again, we have to remember, Medicare pays you 80% of the fee schedule and the patient pays you 20% of the fee schedule. So remember, many of these calculations are going to be on 80% of your total Medicare revenue because 20% is coming in collections from the patient. I think I saw up here, if you are making over $200-something thousand, you're taking care about 85% of the cost. So and then my last slide, why you should care, your job may depend on it. And what I mean by that is two things. If you're young and you're looking to join a group or if you're looking to switch groups, the group has the right to ask you what your MIPS score is. If you have low MIPS scores, I probably wouldn't take you in my practice. If I'm the person interviewing for you for a position with you, I'm going to ask you guys what the MIPS score is for your group. And if I know that that group has taken a hit, I would probably either not join the group or I would say I want a higher salary to offset that hit. And the other thing is it also may affect your ability to stay with your group because if you're the person that's pulling people down, then I'm not sure I would want you to be part of the group.

healthcare reimbursement

financial aspects

legal risks

urogynecology practices

MIPS scores