Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep197: Pay cuts, payer AI and the staff who keep leaving: What we heard at MGMA’s 100th annual conference
Transcript
- Physicians Practice 0:00 We're down here in San Antonio, Texas, for the MGMA Leadership Conference 2026. It's hot, it's bright. There's a lot of sky out there, and we're talking to Kem Toliver. Kem, how you doing today? Speaker 1 0:11 Oh my gosh, Keith, amazing. I'm celebrating 100 years with MGMa. Incredible. Physicians Practice 0:17 Honors Gilbert has been there for 98 of those. Speaker 1 0:20 He doesn't look it though. Speaker 2 0:22 He doesn't. Conference is amazing. It's one of the best I've been to in years. Here, this is our 100th anniversary. I have been around MGM for 98 of those years, quarter of them. So I do have a little experience. We're Speaker 3 0:36 30% of healthcare dollars are waste, right? Not adding one iota of value to patient care, it's administrative burden. It's all of the madness we go through with fighting denials, downcoding, prior authorizations, all of those things that are not adding any value to care. Speaker 4 1:06 Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. From September 27th to the 30th, the Medical Group Management Association, or MGMA, held its 100th annual conference in San Antonio. I was there along with Medical Economics senior editor Richard Payerton and Physicians Practice Managing Editor Keith Reynolds. In today's episode, we're looking back on the biggest conversations from the show: what Medicare plans to pay in 2027, what payers are doing to claims after they go out the door, why staff keep leaving, and where artificial intelligence fits into well everything. So today you're going to hear some highlights from interviews we recorded on site and some takeaways from sessions. With all that said, let's get into the episode. 100 years ago, in 1926, 32 clinic managers from 21 medical groups met at the Madison Club in Madison, Wisconsin, to compare notes on what MGMA still calls the mutual problems of running a practice. A century later, Acting CEO Akash Madaya opened the conference by telling attendees it was MGMA's largest since the pandemic, saying 100 years ago there was no modern reimbursement system, no EHR, no AI, and no telehealth. But there was one thing that was remarkably familiar: healthcare leaders working to make sure patients receive great care. After the show wrapped up, we got a chance to sit down with Akash, and Keith asked him what he was hearing in the hallways. Just Speaker 5 2:40 a lot of engagement. I think there's, I think about why people want to join an association in the first place, and it's really solutions and connection, and where people can look to others in this industry to find a solution. Speaker 4 2:59 The show's opening keynote came from Kieran Griffin, a Grammy-nominated songwriter and former lead singer of NXS. He paired six traits of great teams with great bands, with trust from NXS to collaboration with the Beatles, and the session concluded with the whole ballroom singing an original song that they wrote right there on stage for MGMA's 100th, built around the conference theme from here forward. Under the proposed 2027 Medicare physician fee schedule, the conversion factor, which is the dollar figure that turns each service's value into payment, would fall 1.68 percent for most physicians to $32.84. Physicians who qualify as participants in advanced alternative payment models would see a 1.19 percent drop. Most of that cut comes from a 2.5 percent increase that Congress approved for 2026 only, and the final rule is expected on or about november 1, that same proposal would change what Medicare pays when a physician bills an office visit on the same day as a minor procedure. The most expensive service that day would be paid in full, and every other service at half. MGMA opposes that cut, and with a coalition of specialty groups, has taken it up on Capitol Hill. Speaker 2 3:53 We're not just focusing our efforts and putting in comments and the like. We've been up to the hill on that. We've talked to the White House, we've talked to OMB, and we're part of a coalition called the Same Day Care Coalition, which is made up of many of those specialties like orthopedic surgery, dermatology, and others that would be really dramatically affected. At Speaker 4 4:13 the show, Taya Gordon, CEO of Atlas and Perpetual Healthcare Consulting, told Keith that she'd been asking practices what that cut would mean for them. Speaker 6 4:19 I talked to a group that was kind of metro area, and the doctor said, "Well, that means patients are going to have one problem per day. Got two problems, you're going to have to come back another day," which is so not. I feel like the the ethos that we operate with in healthcare. Yeah. But it was an interesting perspective. I talked to a rural health group, and they said we don't know how we're going to digest it, but we would be the ones who have to absorb that cost. Our patients are driving four hours to see us. We're not going to tell them that they can't see mental health and primary care and their dentist. And you know, if it's an FQHC, all three of those are in the same building. Speaker 4 4:55 Kem Tolliver, CEO of Medical Revenue Cycle Specialists and certified coder herself. Answered the same question. Speaker 1 5:01 Okay, so let me just first start off by saying, and I'm going to get on my soapbox because I'm a certified coder. Please do. Okay, so we, as the medical community as a whole, we've been misusing and misunderstanding how to apply modifier 25 for many, many years. Back in the day when Medicare or CMS approved and paid for consult codes, we misused it, so they took it away. I don't agree with taking it away, yeah, because then it impacts access to care, and we go down a rabbit hole that we should not go down. We want to keep our patients healthy. Speaker 4 5:41 CMS has also proposed ending MIPS after the 2028 performance year. So starting in 2029, physicians outside an alternative payment model would report through MIPS value pathways or MVPs. James Haynes, an associate director of government affairs at MGMA, said that the pathways keep cost measures and many of the reporting problems that physicians already deal with under MIPS and would make some of them worse. And coming up in January, a mandatory model called the ambulatory specialty model begins for select specialists who treat heart failure or lower back pain. Anders Goldberg, MGMA's senior vice president of government affairs, told Keith how practices can find out whether their physicians are a part of that. Speaker 2 6:13 And so there is a list, as you said, it's about 5000, about 5500 physicians that was published two weeks ago, I think, and we would encourage practices that might be again orthopedic surgery, neurosurgery, maybe even anesthesia and pain management, as well as cardiology, to take a look at the list. It's out there on the CMS website. Physicians are listed by NPI and see if those physicians are on the list Speaker 4 6:45 by January 1st. Medicare Advantage and Medicaid plans must also be able to take prior authorization requests electronically straight from a practice's EHR. Anders Gilberg told Keith that when MGMa asked members at the conference whether their EHR vendors had said anything about it, very few people raised their hands. Speaker 2 7:00 Unfortunately, you know there are still moving pieces, but we at this conference spoke to a number of members and said, "Have you heard anything yet about this? Have you heard from your EHR vendors and others?" Very few have heard much about this. I've been hearing some rumblings and being quite concerned that perhaps the payers aren't taking this as seriously as they should, and for all their pledges and commitments to fixing prior authorization, I think this is one of the most important things. One of the most frustrating things I hear is that physicians want to use the fax machine and the like, but the reason they need the fax machine is there's no way to transmit clinical information. This would allow seamless transmission of that information out of the EHR to the the plans, and does exactly what they have been sort of blaming physicians for now for a number of years. And so, for them to kind of back out at the 11th hour, saying it's not ready for prime time, would be unacceptable. Speaker 4 7:57 As far as what comes next, there federal funding runs out on December 11th, and Congress returns for a lame duck session after the November 3rd midterms. Medicare Advantage now covers more than 55% of Medicare beneficiaries. In MGMa's 2026 regulatory burden report, 90% of responding practices said their patients had shifted towards Medicare Advantage, and 79% of those said the shift has hurt their practice. At the show, we sat down with Madison Hinds, an associate director of government affairs at MGMA, and she said that the issues that members raised most over the past year was downcoding. That's when the plan pays a claim at a lower level than the one billed. Speaker 7 8:29 Yeah, so this is this is like such a black box, and I think that's like one of the biggest issues with it overall, right? Prior authorization, you generally know, you know, maybe something needs a request, or you know, you can go through and kind of figure out what processes might you know what might be subject to that. Downcoding is really challenging because it's happening you know kind of in the dark of night. So insert any payer really is able to release a downcoding policy, assuming they release it publicly or in a way that's submitted to practices. But you know, for example, I go and talk to policymakers and the staff all the time, and I print out some of the policies. And I have one policy that I print out as an example that's basically just saying, you know, these four codes may be down coded from a level five to a level three, nothing else. And then there's other examples of of of downcoding, you know, policies by plans that say, you know, we're really only targeting the bad actors, but we don't know what the qualification is for a bad actor, and you know, sometimes they are allowing that provider to appeal whether they're subject to downcoding, but we don't really know what the process is of that or how many providers are impacted, and there's no transparency on the thresholds of who might be impacted. Speaker 4 9:41 She says it's been the biggest increase in what members are reporting. MGM has drafted a bill that would ban automatic downcoding in Medicare Advantage outright, and a fallback version that would allow it only after a plan proves that a physician is upcoded above a set rate and for no more than 90 days. During a government affairs town hall session on September 29th, an attendee who works in oncology in Portland, Oregon, described payers. Use of AI on claims and prior authorization as an arms race, with each side trying to figure out what the other side is doing and find out a way around it. Keith asked Taya Gordon why practices let denials sit in accounts receivable. Speaker 6 10:10 I don't know that they let them sit as much as in the industry. I think so many have gotten used to firefighting and reacting to whatever happens in the moment. There's not a lot of prevention and strategy happening, and it's kind of like if you accidentally let go of a shopping cart and it starts going downhill, you are running to catch it, but it's picking up speed because now it's got gravity behind it, and you can't catch up with that momentum. So it's not like they let it happen as much as it's so overwhelming now, especially with payers using AI and things like that, they're able to review things faster, deny things faster, and we're still pretty manual in terms of our appeals efforts. And so, the the delta it's just too great for them to catch up often. Speaker 4 10:54 Doral Jacobson, CEO of Prosper Beyond, negotiates payer contracts on behalf of practices. Speaker 3 10:58 Denials are really sneaky, you know. A lot of times, and there was just an MJMA stat on this. Most practices do not appeal. So what happens? Who gets to keep that money? The payer. So be really careful. It's really sneaky. You're writing those things off, but really, is it really a contractual write-off? No. You should have been paid those dollars. So you have to account for that as well in your proposals with payers. Speaker 4 11:21 Paya Gordon has one assignment for administrators back from San Antonio. Speaker 6 11:24 Immediately for everybody, run a report of the CPT codes you build out for the last six months, and which CPT codes you got paid for that same claim ID for the last six months. If those are different, it's probably because you're being down coded. Some payers are telling you, some payers are just doing it, and it comes through looking like a paid claim. Speaker 4 11:43 In MGMA polling this summer, 84% of medical groups said operating costs were higher than in 2025. Only 47% said revenue was up, and 36% said that it dropped. Dave Gans, a retired MGMA senior fellow who spent 45 years with the association, laid out three ways for practices to protect their margins. First, get more productive. Second, get more efficient. And third, collect more of what they've already earned. He told attendees that productivity should come first. In MGMA's data, primary care physicians in the top quarter of physician-owned practices produce more than 7,585 work RVUs a year, compared with fewer than 4,165 in the bottom quarter. Barbara Ireland, a senior operations analyst at Murfreesboro Medical Clinic presented on revenue hiding in reports the practice has already run. In one pediatrics group, she counted about 58,000 vaccines given, but only about 25,000 administration codes billed. Coders had been told to bill no more than two components per combination vaccine, a limit that Ireland said current guidance didn't support. The practice retained its coders, rebilled 18 months of claims, and recovered more than $200,000, Ireland said that payers are going to pay what's on the claim, and getting everything that a practice has actually earned onto that claim is nobody's job but the practice. Keith asked Andrew Swanson, MGMA's chief customer success officer, to pick a single number to benchmark. Physicians Practice 12:54 If an administrator can benchmark only one number next year, what do you think it should be? Andy Swanson 13:00 Our members are suggesting to us the single and by far biggest issue is reimbursement, and so the way I would begin to analyze and combat that is by looking at gross charges compared to net medical revenue. So, what am I charging for? What am I actually collecting? And what's the delta? Because that's where you start digging into what's causing the delta. Speaker 4 13:22 Doral Jacobson said the same homework decides payer negotiations. Speaker 3 13:26 Most of the negotiation happens before you ever get to the table with the payer, so that part that's uncomfortable, super duper small. But 90% of it is homework, meaning get your executed agreement, get your fee schedules for all of the products, so you know exactly what they're paying you today. Because one of the things that's really uncomfortable for practices is they'll say things like the administrative burden's too great, so we need more. The payer is going to ask you questions, so you need to know what your answers are before you ever go to the table. Or they love to say this: you are paid top of market. If you had your homework done, you would know that's baloney. So doing your homework is going to help you from a confidence perspective, and it's going to help you address all of those questions that the payer is going to ask you. Speaker 4 14:11 In a May MGMA stat poll, 28% of medical group leaders said staff turnover was higher in 2026 than in 2025, concentrated among medical assistants, clinical support staff, and front desk workers. We sat down with Rachel Brace and Nicole Hart, the co-founders of the human resources firm Backpocket Talent, and they told us that replacing one employee who earns under $75,000 costs 16 to 20% of that person's salary on average. Rachel Brace compared that with a $2,000 retention bonus paid at six in 12 months. The Speaker 8 14:37 national average is between 16 to 20% of a person's salary in the medical industry that's making under 75 grand. That's just the source, and that's you know we use that quite a bit in our presentation. So if you're looking at something that's 18 percent of of cost for turnover and a retention. Bonus that you're going to give them at six months and maybe 12 months is only going to be $2,000. You have to weigh those options. You're you're paying the money regardless. You just need to shift the focus that hey, we should be paying money for retention, not to have them walk out the door. It's really it's it's as simple as that. And those are it's you know when I was in a practice, it's like oh should we give them more money should we do this and we never really looked at how much it costs when somebody walks out the door because you're usually scrambling and you're not thinking straight. Speaker 4 15:32 Andrew Swanson also brought MGMA's latest numbers on how long patients wait to get in. Andy Swanson 15:36 This is where I actually brought some numbers with me. Fantastic. I mean our numbers are saying third next available visit time increase for a new patient visit in primary care from nine and a half days to 13 and a half days. Existing patients from five days up to eight days. In surgery, doesn't surgical care doesn't see quite as dramatic, but still a pretty significant rise from 8.4 days to 9.6 for a new patient, and from five and a half days to seven and a half days for existing patients. So access is getting worse somehow. A decade ago, it was: Are you open for a half day on Saturdays? There aren't groups who aren't open on Saturdays. Yeah, everybody's open on Saturdays. Now it's oh, you've extended hours to 6pm. How about 7pm? Oh, we're opening the doors at 830. How about seven? I mean, these are the conversations, right, to get more folks in and through. But in the end, it's it's sheer visit volume tied to number of providers in a practice. Speaker 4 16:38 Billing jobs are among the hardest for practices to keep filled, Kem Toliver once worked as a biller herself. Speaker 1 16:42 So I was a biller at one at one point in my career, and I look back and you know I had to I had to submit paper claims HIFFA 1500 the red and white forms, and what I what I think of putting my biller hat on from you know 1999 to to you know the early 2000s, we didn't have access. I didn't have access to all of the technology that a biller has access to now. And if I were a biller today, and my leadership didn't afford me access to the technology that could be used to make my life easier, and forced me into repetitive manual processes where I'm just literally pushing buttons, as opposed to using my skill set to make processes in my revenue cycle and for my team better, I'd be irritated. I'd be frustrated every single day. So I really believe that if we could improve the experience of our RCM team, we'd be able to keep a lot of them longer. Speaker 4 18:05 MGMA's 2026 provider compensation and productivity report found that physician pay rose in 2025, even as patient visits fell in all 23 specialties that it tracks. In primary care, pay rose 2.33 percent, short of the 2.7 percent rise in inflation. Hybrid models that blend a base salary with quality and other incentives now make up more than three quarters of reported compensation structures. Andy Swanson 18:25 I mean, I I would not don't consider this a trend just yet. It's one year, and the inequity or ratio of pay to productivity had been going up and up and up. Meaning, productivity had been outpacing pay gains for a very long time. Speaker 9 18:42 Yeah, Andy Swanson 18:42 so I don't think there's all those employers of physicians should not be racing out and panicking over this. Speaker 4 18:50 Monique Delgado, former CEO of Integrated Medical Services in Arizona and now market president for the West Region of Vitalize Health, presented on physician pay and told us that physicians should drive the design of their own compensation, with administrators showing them the data and what each choice does to the bottom line, bringing physicians in only after a plan is finished, she said, often goes badly. Dr. Dale Patterson, a family physician and president of the Beacon Medical Group in Indiana and Michigan, presented on what he calls renter and owner physicians. He told us that renters show up and do the work, but expect someone else to fix the problems that they see. But owners, he said, they treat the practice as their own, and they work to leave it better than when they found it. Speaker 10 19:23 Yeah. So the analogy, really, way I think about it is, you know, when you rent an apartment or you buy a house, right? And when you when you live in an apartment that you know you're only going to be in for a short time, you don't want to make any investments that you're going to leave behind or you know prepare for the future. When you buy a house and you move in, you have a long-term thinking where I'm either going to be here a long time, or I want to, you know, make the house stronger, better, so that if I do sell it or I do something different, it's in a better position than it was when I moved in. And really, that's what we're looking for by moving physicians from renter with the analogy of rent. To owner, what we would call the renter physician is somebody who shows up for their job because it's work and they do it on a daily basis. But they think other people are going to fix the problems that come up, and they rely on you know look look outside of themselves for solutions, and they just you know come and do their job and go home. From a owner perspective, we want people to be engaged with the organization and feel like they're part of the solution, and they're coming up with the solutions. They're coming up with the way we take care of patients. They feel like it's their practice, and they're a leader there, and they're building something that's better than what it was before they got there, so that they are taking better care of patients, and they're building a system that they can be proud of. We Speaker 4 20:45 also sat down with John Dornboss, who spent most of his 14 NFL seasons with the Philadelphia Eagles as a Pro Bowl long snapper until a 2017 team physical found an aortic aneurysm and sent him into emergency open heart surgery. John gave a main stage keynote on September 28th, and we asked him what he would tell physicians who feel worn down? Speaker 9 21:02 Because no matter what relationship you're in or career you're in, you're going to have moments where all of a sudden you just kind of feel like you're hitting a wall and you're burned out. And why am I doing this? And sometimes when you make a change, you're going to get right back to that point as well. And so keep being you, keep making the world a better place. And when you get burned out, just take a deep breath. You're where you belong. You're where you're where we need you, and hopefully, you're in a position that you've been working your whole life to get to. So don't forget how hard you worked to get there. And I'm a patient. You're making the world a better place, and we need people like you. So keep on keeping on. Speaker 4 21:38 Seema Verma, who ran CMS during President Donald Trump's first term and is now an executive vice president at Oracle Health and Life Sciences told the conference that healthcare is still at the very beginning of using AI. She joked that healthcare is the only reason the fax machines still exist, and she said the practices can't have an AI strategy without a data strategy. Julia Rosen, MGMA's senior vice president of IT, told us that practices unsure of where to begin should start with the revenue cycle, where she said practices see some of the biggest returns. Her example was uploading remittance files to a HIPAA compliant AI tool and asking for the most common causes of denials. Speaker 11 22:10 You know, especially for practices who are who are strapped for money, start with the tools you have. Start with the native EMR, the native AI tools in your EMR. Start with just the copilot that you are using administratively in your office that you probably already bought in May some in some packages it's already included you know with different Microsoft Microsoft stacks so so again start with what you have don't overcomplicate it you know don't look at the sea of you know 400 different AI tools and try to decide between them with you know your small investment dollars, Speaker 4 22:43 Tatiana Melnick, a Tampa healthcare attorney, said the patients in California have filed class actions against practices and hospital systems using AI scribes, saying they never consented to their use. Her recommendation is to ask patients for affirmative consent and have a process ready for those who say no. Speaker 12 22:57 Not everybody is comfortable with those technologies, and so you, as the practice, have to decide: Can we accommodate the patients that are not comfortable? Can we just turn these technologies off, or is it going to be like what practices did with EMRs, where a lot of them said, "Look, our process now is to use EMRs, and if you're not comfortable having your records stored electronically, then you simply can't be our patient. But from my view, the best place to put some of these disclosures and address these consent issues is through the notice of privacy practices, which is something that practices are already supposed to do and use as part of HIPAA. And there is no reason why they can't add AI terminology to their existing notice of privacy practices. Speaker 4 23:44 Keith asked Andrew Swanson whether AI has anything to do with what's happening to staffing, and here's what he said: Andy Swanson 23:49 Yes, but the macro data about positions created in healthcare would tell me that we're still throwing people at problems. I don't yet know if that's a good thing or a bad thing. I mean, I think that it there there has to be a person at the end of that technology making sense, not just of its implementation, but of its output as well. And I think rightfully so, a lot of our members in the medical group community at large is is piloting, they're testing, they're feeling their way through this technology adoption, and they still need people and people with expertise to make sure that the tool is doing it the right way and producing the same outcomes that we would expect people to do. Speaker 4 24:28 We close most of our conversations in the same way, asking for one thing that an administrator could do as soon as they got home. You can find most of those responses over at physicianspractice.com. But Akash Madaya, he gave two of them. Speaker 5 24:39 I would say two things. One, pick a metric that matters most to your organization and just review it every week. Like there's, you know, start small. You got to start somewhere, right? Like, yeah. So figure out what's the metric that could really move your organization from good to to great. So pick pick that, and then the other thing I'd say is schedule one conversation with a peer outside your organization. Find them in the MGMA network, or just find find the clinic down the street, or a system down the street, or in another state. Speaker 1 25:20 It's really great to be around people who share your experiences, and I was I was mentioning this to Matt that my husband, high school sweethearts, we've been together for a really long time, and when people ask, "Oh, what does your wife do. It's like I don't know. She's in healthcare. I don't know what she does. Most people cannot interpret what we do, right? Yeah. But every one of these hundreds of people walking around in this conference center knows exactly what we're doing, and we know the impact that we're making. So it's it's refreshing to be around people who understand what you're doing, and we're all on the same mission. Speaker 4 26:10 Richard Perriton, Keith Reynolds, and I, Austin Latrell, covered sessions and sat down with speakers all week. That coverage, including session recaps, interviews, and our 10 biggest takeaways for physicians and for practice leaders, is on the MGMA conference pages at medicaleconomics.com and physicianpractice.com. Once again, this was our look back at MGM's 100th annual conference, featuring conversations recorded on site with Anders Gilberg, senior vice president of government affairs at MGMA, Andrew Swanson, chief customer success officer at MGMA, Kempt Oliver, CEO of Medical Revenue Cycle Specialists, Taya Gordon, CEO of Atlas and Perpetua Healthcare Consulting, Julia Rosen, MGMA's senior vice president of IT, Tatiana Melnick, a Tampa healthcare attorney, John Doranboss, a former NFL Pro Bowl long snapper and America's Got Talent finalist, Dr. Dale Patterson, a family physician and president of the Beacon Medical Group in Indiana and Michigan, Rachel Brace and Nicole Hart, co-founders of the human resources firm Backpocket Talent, and Madison Hines, an associate director of government affairs, and Doral Jacobson, CEO of Prosper Beyond, along with Keith's conversation after the show with Akash Madaya, acting CEO of MGMA. And if you want more on payer contracts, Doral Jacobson leads the payer contracting session at the free Physicians Practice Practice Academy later this week on Thursday, October 29th, from 12 to 4 p.m. Eastern. You can find the link to register for that absolutely free in the show notes below. But with all that said, my name is Austin Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts. Also, if you think the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart business and medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Lartra. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank you.