Medicare's plan to pay half for same-day care, with Anders Gilberg of MGMA

A patient comes in for an exam, the physician finds something that needs a small procedure and takes care of it in the same visit. Medicare's proposed 2027 physician fee schedule would pay the higher-valued of those two services in full and cut the other one in half. Anders Gilberg says the result could be patients asked to come back the next day for care they could have gotten in one trip.

Physicians Practice Managing Editor Keith Reynolds sat down with Gilberg, senior vice president of government affairs at the Medical Group Management Association (MGMA), on Sept. 14, the day public comments on the proposed rule closed.

Gilberg explains why MGMA is fighting the same-day proposal, why budget neutrality rules keep pitting specialties against one another and what the bipartisan Patients First Act would change. He also covers the mandatory Ambulatory Specialty Model that starts Jan. 1 with its participant list still unpublished, what else is sitting in the lame-duck pile and the artificial intelligence policies he says every practice should put in writing.

The Centers for Medicare & Medicaid Services has posted a fact sheet on the proposed rule, and Gilberg expects the final 2027 fee schedule on or about Nov. 1. He will be at the MGMA Annual Conference in San Antonio, Sept. 27-30, along with the Medical Economics and Physicians Practice teams.

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Music Credits:

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Editor's note: Episode timestamps and transcript produced using artificial intelligence (AI) tools.

0:00 – 0:23 | Cold open. Gilberg on patients being asked to come back the next day for a procedure.

0:23 – 1:29 | Introduction. Austin Littrell previews the episode and MGMA's centennial Annual Conference in San Antonio, Sept. 27-30.

1:29 – 1:59 | Meet Anders Gilberg. Keith Reynolds welcomes Gilberg back on the day public comments closed on the proposed 2027 fee schedule.

1:59 – 4:41 | The one change MGMA wants. Another conversion factor cut is in the rule, but Gilberg says the change Medicare can still make on its own is dropping the proposal to pay half for one of two services billed the same day. He walks through a dermatology example and the Same Day Care Coalition's opposition.

4:41 – 5:56 | The Patients First Act. The bipartisan doctors caucus bill would tie annual fee schedule updates to the Medicare Economic Index, rework budget neutrality and reform quality reporting.

5:56 – 8:06 | Why Medicare can't fix budget neutrality alone. The $20 million trigger is written into law. Gilberg points to a 2024 add-on code whose use was overestimated by roughly $1 billion, a cut physicians never got back.

8:06 – 9:19 | The quiet part: practice expense. Practice expense values cover overhead, and Gilberg explains why keeping the lights on, paying staff and buying supplies makes this an administrator's issue.

9:19 – 11:10 | The Ambulatory Specialty Model starts Jan. 1. Gilberg says practices aren't ready because the participant list still hasn't been published, and notification is expected to run through a portal each physician checks individually.

11:10 – 12:13 | P2 Management Minute. Keith Reynolds shares practice management tactics and invites listeners to send in their own, then turns to the lame-duck session.

12:13 – 13:45 | Will Congress fix the cut? Gilberg on why modest cuts are harder to fight than big ones, drawing on his years working through the sustainable growth rate formula.

13:45 – 15:38 | What else is in the lame-duck pile. The work geographic price index floor and the expiring alternative payment model incentive bonus, plus why a retroactive fix in the new year is the outcome nobody wants.

15:38 – 18:51 | AI guardrails inside the practice. Governance, written policies on what gets typed into tools like ChatGPT, HIPAA and malpractice exposure under laws already on the books, and keeping the human element in the physician-patient relationship.

18:51 – 19:39 | What to watch next. The final rule is expected on or about Nov. 1, and Gilberg says practices won't know until the 11th hour whether the same-day cut survived.

19:39 – 20:36 | San Antonio. Reynolds and Gilberg on the MGMA Annual Conference, where the association marks its 100th anniversary.

20:36 – End | Closing thoughts and outro. Reynolds thanks Gilberg, and Littrell wraps the episode.