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Outpatient Visit Evaluation & Management Changes for 2021

Outpatient Visit Evaluation & Management Changes for 2021

For more than 25 years, the American Medical Association has utilized the 1995 or 1997 guidelines for Evaluation and Management (E/M) services in the Current Procedural Terminology (CPT).  The E/M codes have expanded over the years but until now, there has been no update to the elements, in which, we choose a level of service. The Centers for Medicare and Medicaid Services in partnership with the American Medical Association (AMA) collaborated on changes to reduce the administrative burden in documenting outpatient visits for new and established patients.  

The revised guidelines pertain to the new patient codes 99201-99205 and established patient codes 99211-99215.  The revision was announced as part of the 2020 Physician Fee Schedule but does not occur until 2021 due to the many preparations to support this endeavor. The AMA is actually updating the code description for the specified codes, which affects all carriers, not just CMS.  The 99201 code is eliminated for 2021; the remaining codes will retain reimbursement for each code, which is a change from the proposal to condense some codes to a combined rate.  

The inclusion of time has been an explicit factor in the definitions of E/M services in the CPT codebook since 1992.  Beginning in 2021, with the exception of 99211, time alone may be used to select the appropriate level of service. For coding purposes, total time includes both face-to-face and non-face-to-face time spent by the physician or other billable healthcare professional the day of the encounter.  Total time does not include staff preparation time.  

Physician or other provider professional time includes the following:

  • Preparing to see the patient (review test, past visits)
  • Obtaining or reviewing separately obtained history
  • Performing a medically appropriate exam
  • Counseling and education for the patient/family
  • Ordering medication, tests or procedures
  • Referring and communicating with other providers
  • Documenting clinical information 
  • Independently interpreting results (not separately reported) and communicating results
  • Care coordination

Another option for choosing the level of the new or established E/M in 2021 is medical decision-making.  Medical decision-making has always been an element in the level of each new and established visit but never as a standalone element.  The concept of MDM does not apply to CPT 99211. When using MDM in selecting the level of the visit, the documentation should reflect the number and complexity of diagnosis addressed in the encounter.  The amount and complexity of data reviewed or analyzed is also required. The risk of morbidity should be documented to support the level of medical decision-making.  

These changes will most likely reduce the administrative burden for all specialties, but it is also disruptive.  The implementation of electronic medical records has had a huge impact on workflow at the physician/provider level as well as the staff.  Large and small practices have spent time developing comprehensive templates, triage teams, scribe teams, etc. to reduce the physician burden and feed quality data to the EMR.  Each practice will need to analyze the process in which they prepare a patient and how they decide medical necessity of history obtained. Each provider has a different patient schedule; in the past time spent with the patient was explicit.  In 2021, billing on total time spent could send a message of compliance. If a provider sees 25 patients a day coding a level 4 visit, they would be stating they spent 49-60 minutes per patient or 20 hours on that date of service inpatient care.  I do not anticipate providers seeing a higher volume of patients will bill on total time, it is not a common practice for providers to assess time spent with each patient.  

Most providers will probably code using the medical decision-making component. In the past, providers could reach a level 4 established visit based solely on the history and exam, which is not so in 2021! There will be prolonged service codes available to bill in addition to a new or established visit in cases when extended direct patient time is spent with clinical staff and supervised by the physician. 

Managers will spend 2020 assessing the many facets to consider the 2021 changes.  How will they maintain quality data entry in the EMR without the many clicks feeding the data?  Providers may use voice recognition to transcribe the medical decision-making as they did before the EMR.  In a potentially massive cost rebalance, CMS also finalized the relative value units (RVU) for the group of oft-used E/M services, which will determine 2021 pay rates. The RVU changes, for example, would boost payments for code 99214 – the most-reported E/M code – from $109 to $136 per claim, a 25 percent increase. Rates for 99213 would jump nearly 30 percent.  

Changes could occur before 2021, but it’s not likely we will move totally away from the decisions already made by CMS and the AMA.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

Posted in: Management, Members

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Call for Elective Offices

Call for Elective Offices

The following are positions for offices in the Medical Association which will be elected at the 2020 Business Session. Nominations for statewide offices are presented through a Nominating Committee process. District offices (*) are nominated from district caucuses.  Qualified candidates shall have been regular, government or academic employee members of the association for at least three years after completion of their residency or fellowship.




Vice President

Board of Censors (3-year term)

District 1          Charles Max Rogers, MD*                    Eligible for re-election

District 2          Michael T. Flanagan, MD*                   Eligible for re-election

At-Large 1        Mark H. LeQuire, MD                          Eligible for re-election

At-Large 2        Beverly Jordan, MD                             Eligible for re-election

AMA Delegation (2-year term)

Delegate 2        Boyde J. “Jerry” Harrison, MD              Eligible for re-election

Delegate 4        George “Buddy” Smith, Jr., MD            Eligible for re-election

Alt. Delegate 1 John S. Meigs, M.D.                             Eligible for re-election

Alt. Delegate 2 William Schneider, M.D.                      Eligible for re-election

Alt. Delegate 3 Harry Kuberg, M.D.                             Eligible for re-election

Alt. Delegate 4 Raymond Broughton, M.D.                   Eligible for re-election

Council on Medical Education (3-year term)

District 1          Holly G. Pursley, MD*                         Not eligible for re-election

District 6          Tracy Jacobs, MD*                               Eligible for re-election

District 7          Catherine Skinner, MD*                       Eligible for re-election

At-Large 1        Russell Barr, MD                                  Not eligible for re-election

Council on Medical Service (3-year term)

District 3          Arden Aylor, MD*                               Eligible for re-election

District 7          Matthew R. Thom, MD*                       Not eligible for re-election

At-Large 3        Deborah Kolb, MD                               Eligible for re-election


The deadline for submitting nominations to the nominating committee is Thursday, January 9, 2020. Please submit nominations to

Posted in: Leadership, Members

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PEEHIP Transitioning to Humana Effective January 1st

PEEHIP Transitioning to Humana Effective January 1st

Medicare-eligible retirees of the Public Education Employees’ Health Insurance Plan (PEEHIP) will be moving to the Humana Group Medicare Advantage Preferred Provider Organization (PPO) plan for their healthcare coverage, effective January 1, 2020.

Humana will be hosting a series of webinars as they lead up to the PEEHIP transition on January 1st.  These will be educational seminars on doing business with Humana.  Topics will include claims filing, claims disputes, overpayment processes and Availity functions.


Nov 11, 2019 12:00 PM EST
Webinar ID: 665-901-411

Dec 11, 2019 1:00 PM EST
Webinar ID: 722-111-459

Dec 16, 2019 1:00 PM EST
Webinar ID: 823-226-851

2. Choose one of the following audio options:

When the Webinar begins, you will be connected to audio using your computer’s microphone and speakers (VoIP). A headset is recommended.

— OR —

If you prefer to use your phone, you must select “Use Telephone” after joining the webinar and call in using the numbers below.

United States: +1 (914) 614-3221
Access Code: 825-036-259
Audio PIN: Shown after joining the webinar

Questions? Contact Shawn Kent.

Posted in: Insurance, Members

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Closing Your Medical Practice – Calling it Quits!

Closing Your Medical Practice – Calling it Quits!

There is a lot of media attention to “Baby Boomers” retiring with more than 10,000 leaving the workplace every day.  Anyone closing a business has a list of items to address before selling the business or closing the doors, but there is a unique set of considerations when a physician practice owner elects to retire or stop providing service.  A medical practice provides a needed service to patients and a community unlike other businesses. The Board of Medical Examiners in each state has rules, in which the physicians should notify the patients and transfer care timely without restricting the medical records needed to continue care.

I recently worked with a practice that was receiving calls from patients who were trying to find a new physician.  A physician had left town and his patient records were in an electronic medical record, in which the patients had no access.  These patients were suffering from chronic disease and receiving biologic treatment; the new practice trying to assist these patients would need the patient record to care for them.

If a physician plans to retire, leave town or sell his practice, he should contact an accountant or legal representative to assist in a plan. It is important to notify your local medical society of your plan to sell or close so they can assist you. If there is value in the practice, a valuation may be performed to facilitate a sale to the hospital or another physician or group.  The value of a practice is determined by fair market value of accounts receivable, assets and other considerations. If a physician owner has fallen ill, the plan or timeline to work through a checklist could be limited.

Once a physician has chosen an advisor, a plan is prepared to sell or close the practice.  A timeline of no less than six months should be set to notify patients and staff, transfer records and value the building and assets for sale.  The practice should no longer accept new patients to the practice if it is closing. The patients must be notified in writing at least thirty days before closure and the practice must facilitate the transfer of medical records to a physician of the patient’s choosing.  If another physician will “take over” the practice, a custodianship of medical record arrangement can release the physician owner of the responsibility of maintaining the paper or electronic charts. The patient must be notified who is responsible for the medical record should the patient decide to change providers after the physician is retired.

A checklist will provide guidance regarding the many notifications that must take place after the last date of service to patients.  The accounts receivable are generally finalized in 60-90 days; insurance companies should be given a forwarding address for residual payments.  Vendor contracts should be reviewed for “out clauses.” Insurance agents who cover the business should be notified along with state agencies. Business records, such as payroll records, tax records, etc. have retention guidelines you should follow.

Calling it quits is easier in other industries than healthcare.  Physicians provide a service that includes a relationship and a valuable record to a patient; it is not to be taken lightly.  If you are planning a change in ownership or retirement, reach out to an advisor for assistance.


Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

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Doctors Unite in Support of Physician Office Exemption

Doctors Unite in Support of Physician Office Exemption

We called and you answered!  Thank you to all the physicians who answered the urgent call-to-action and quickly signed on to the Medical Association letter (more than 600 doctors to date!) challenging the Alabama Hospital Association (ALAHA) and its member facilities’ contentions about the appropriateness of the physician office exemption (POE) from CON review.

As you know, ALAHA recently submitted a letter complaining of increasing instances of physicians performing interventional procedures in their offices instead of in acute care hospitals. ALAHA’s complaints are not in line with Alabama law and their letter was an attack on the practice of medicine and the services physicians safely provide patients in their offices.

Below is the letter the Medical Association sent in response to ALAHA’s assertions. We will continue to update you as things progress.

Thanks again!

Posted in: Advocacy, Members

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Fraud and Abuse Facelift: Proposed Changes to Stark, AKS, and Beneficiary Inducements CMP

Fraud and Abuse Facelift: Proposed Changes to Stark, AKS, and Beneficiary Inducements CMP

As part of its “Regulatory Sprint to Coordinated Care,” the Centers for Medicare and Medicaid Services (“CMS”) and the Health and Human Services Office of Inspector General (“OIG”) released proposals to modernize the Medicare Physician Self-Referral Law (“Stark Law”), Anti-Kickback Statute (“AKS”), and Beneficiary Inducements Civil Money Penalty (“CMP”) (collectively, the “Proposed Rules”). The Proposed Rules add five new Stark Law exceptions, seven new AKS safe harbors, and an additional exception to the definition of “remuneration” under the CMP. Several of the new Stark exceptions and AKS safe harbors relate to value-based arrangements and largely mirror each other. Other new exceptions and safe harbors relate to the donation or use of cybersecurity items and beneficiary incentives in the coordination of patient care. These proposals are by no means final (stakeholders have until December 31, 2019 to comment on them), but if finalized, they may provide more flexibility for physicians and other providers to pursue value-based arrangements, as well as greater clarity with respect to existing Stark Law requirements.


Value-Based Arrangements under Stark and AKS

Three new Stark exceptions and four new AKS safe harbors relate to value-based arrangements in which one or more participants in a value-based enterprise (“VBE”) pursue one or more value-based activities and purposes. Value-based purposes include coordinating and managing care, improving quality, reducing costs or growth of expenditures (without reducing quality), and transitioning from fee-for-service care to quality care for a target patient population. Value-based activities include providing items or services (not including a referral), taking an action, or refraining from taking an action, in furtherance of a value-based purpose.

There are separate exceptions and safe harbors for value-based arrangements involving: (i) full financial risk, (ii) meaningful/substantial downside financial risk, and (iii) remuneration for improving quality, health outcomes, and efficiency. Full financial risk means that the VBE is prospectively financially responsible for the cost of all patient care items and services covered by the applicable payor for each patient in a target patient population over a specified period of time. Meaningful/substantial financial downside risk means that a physician is responsible to the VBE for specified percentages of the value of the remuneration paid to the physician or is responsible on a prospective basis for the cost of all or a defined set of patient care items and services for each patient in the target patient population over a specified period of time. For value-based arrangements incentivizing improvements in quality, health outcomes, and efficiency, the proposed Stark exception would allow both financial and in-kind remuneration related to value-based activities and meeting objective and measurable quality and performance targets. By contrast, the similar proposed AKS safe harbors focus more on in-kind remuneration, including anything of value given either to VBE participants to help coordinate and manage patient care and patient engagement tools and supports given to patients to address social determinants of health and incentivize the patient’s participation in their health care. In addition to the mirror exceptions and safe harbors generally described above, the AKS Proposed Rule sets forth an additional safe harbor for remuneration exchanged between participants in a CMS-sponsored model, such as an ACO or bundled payment model.

There are common requirements for each of the exceptions and safe harbors listed above. For instance, the VBE must generally set forth in a signed writing the terms of the value-based arrangement, including a description of the nature and extent of the risk assumed under the arrangement, the value-based activities involved, the target patient population, and the type and cost of the remuneration involved. Additionally, the VBE or VBE participant offering remuneration under a value-based arrangement must not take into account the volume or value of referrals or otherwise condition the remuneration on referrals of patients who are not a part of the target patient population or business not covered by the value-based arrangement.


Other Stark Additions and Clarifications

The Stark Proposed Rule contains an additional exception for nominal payments to physicians ($3,500 annually, indexed for inflation) for the provision of items and services to an entity. The new exception applies even if there is no written agreement, provided the compensation does not relate to the volume or value of referrals or other business generated by the physician, does not exceed fair market value, and is commercially reasonable, among other requirements. The Stark Proposal also modifies certain existing Stark exceptions and clarifies a number of definitions. For instance, it adds flexibility to the “Electronic health records items and services” exception to include nonmonetary remuneration in the form of cybersecurity software and services. It also purports to clarify the meaning of “fair market value” and “commercially reasonable.” Although additional clarification of these terms would probably be useful, the Stark Proposed Rule at least clarifies that an arrangement does not have to result in a profit for one or more of the parties in order to be commercially reasonable.


Beneficiary Inducements

The Proposed Rules provide additional protection for remuneration to beneficiaries under AKS and the CMP. Under a new AKS safe harbor, beneficiary incentive payments to beneficiaries assigned to an Accountable Care Organization (“ACO”) under the Medicare Shared Savings Program (“MSSP”) would not constitute “remuneration” for purposes of AKS, if they meet the ACO beneficiary incentive requirements under MSSP. Somewhat similarly, the provision of telehealth technologies to patients with end-stage renal disease (“ESRD”) is not considered “remuneration” for purposes of the CMP if the technologies contribute to the provision of telehealth services related to the patient’s ESRD, is not of excessive value, and meets other requirements.



This article simply provides a high-level overview of the concepts addressed in the Proposed Rule. A more in-depth review of the Proposed Rules reveals additional requirements and subtle differences in the rules that will be material to parties trying to navigate them successfully.  Again, these rules are far from final. However, they indicate an intentional shift toward value-based care and relaxed regulatory requirements to help foster such care. Physicians and other providers have an opportunity to provide feedback on these proposals and hopefully refine them to workable exceptions that will enable the further adoption of value-based arrangements which are being promoted by current payment policy.

Article submitted by Christopher L. Richard, Esq. with Gilpin Givhan, PC in Montgomery, AL.

Posted in: Legal Watch, Members

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Medical Association Opposes Scope of Practice Expansion Executive Order

Medical Association Opposes Scope of Practice Expansion Executive Order

President Trump issued an executive order on October 3, 2019 as an alternative to “Medicare for All”. Initially, the order was titled “Protecting Medicare From Socialist Destruction” but was changed to “Protecting and Improving Medicare for Our Nation’s Seniors.”

The executive order does include some items that the Medical Association of the State of Alabama supports; however, there are concerns that the language within the order appears to expand the scope of practice of non-physician providers.

President Trump directed the Secretary of Health and Human Services, Alex Azar, to propose a new regulation within the next year that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements […] that are more stringent than applicable federal or state laws require and that limit professionals from practicing at the top of their profession.”

Possibly the most alarming language found within the order is that President Trump gave Azar only one year to propose regulations that would “ensure that items and services provided by clinicians, including physicians, physician assistants, and nurse practitioners are appropriately reimbursed in accordance with work performed rather than the clinician’s occupation.”

Mark Jackson, the Executive Director of the Medical Association, believes the language within the order should raise serious concerns for physicians in Alabama. “We believe that medical school matters and physicians should always be the head of the healthcare team,” Jackson says. ”Our mission is to promote the highest quality of healthcare for the people of Alabama. Therefore, we fully support physician-led team-based care and will be co-signing a letter with the American Medical Association as well as working closely with our Congressional Delegation to address our concerns.”

View the letter here.

Posted in: Advocacy, Medicare, Members

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CMS Is Expanding Its Enforcement Ability

CMS Is Expanding Its Enforcement Ability

Pursuant to a new rule, entitled Program Integrity Enhancements to the Provider Enrollment Process, the Centers for Medicare & Medicaid Services (“CMS”) is expanding its ability to combat fraud and abuse within the healthcare industry.

Under the new rule, CMS will be able to identify individuals and entities that pose a fraud and abuse risk solely based on “affiliations” with other entities that have been sanctioned by CMS. CMS can then take steps to prevent such identified individuals and entities from participating in the Medicare program. At the request of CMS, enrolling providers will disclose
any current or previous “affiliation” with an organization that has uncollected debt (regardless of amount and regardless of appeal status), experienced a payment suspension, been excluded, or had its billing privileges denied or rescinded (regardless of the basis). As used within the new rule, “affiliation” would include, among other things, an individual with 5% or greater indirect or direct ownership interest, officer, director, individual with operational or managerial control, or any reassignment relationship.

The provider community has expressed a number of concerns with this new rule, as the new rule gives a large amount of discretion to CMS without comparable notice or remedy to the provider. Consequently, in light of this new rule, Medicare providers and suppliers need to carefully and thoroughly examine any individual with whom it has an “affiliation” relationship to
avoid negative consequences.

The rule takes effect on November 4, 2019.

Kelli Fleming is a Partner at Burr & Forman LLP practicing exclusively in the firm’s healthcare industry group.

Posted in: Legal Watch, Medicaid, Medicare, Members

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Guidance on Practice and Ethical Issues

Guidance on Practice and Ethical Issues

The Medical Association’s Office of General Counsel can help guide members on certain practice and ethical issues.  The Office is comprised of the General Counsel, Cheairs Porter, and Paralegal, Angela Barentine.  The General Counsel is the chief legal advisor to the Board of Censors, and provides legal advice daily to the Executive Director.

Mr. Porter, a Montgomery native, started as General Counsel of the Medical Association in December 2012.  He currently has over 23 years of related legal experience, including an advanced legal degree in health law and substantial practice in regulatory health care matters.

Ms. Barentine, a Milbrook native, graduated Magna Cum Laude in 2002 with a B.S. from Auburn University.  She began work with the Medical Association in April 2015.  She has a Master of Public Administration with a concentration in Health Care, and a Certificate in Non-Profit Management and Leadership.  Ms. Barentine has 20 years of related experience.

While the Office is very busy handling a wide mix of contracts, business issues, legislative, administrative law (agency) matters and matters coming from various departments, as well as staffing the Council on Medical Services, it also can provide general guidance on the law in particular areas, such as:

  • Separation from a practice;
  • Starting a practice;
  • Medical records policy;
  • HIPAA issues;
  • Certain prescription drug matters;
  • Overpayments;
  • Ethics;
  • Medicaid; and
  • Some billing and charging issues.

If you are searching for general guidance, please feel free to contact Cheairs Porter at (334) 954-2540 or Angela Barentine at (334) 954-2541 for assistance.

Posted in: Legal Watch, Members

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All Things 401(K): Participants Education, Plan Structure and Assessments

All Things 401(K): Participants Education, Plan Structure and Assessments

The ultimate goal of any retirement plan is for participants to prepare for retirement, but Physicians must also maintain the appropriate structure of the plan. How can you be sure everything is handled correctly? Below, one of our 401(k) plan experts, Jack Adams, answers a few frequently asked questions about 401(k) plan education, structure and design.

Question: How do we prepare our participants for retirement?

Answer: With participants, one of the most important things you want to do is talk to them about the reason they need to save for retirement. Other advisors seem to focus on the investments, but if a participant isn’t properly saving for retirement, they will never reach their ultimate goal. What we do in our retirement meetings, from an education standpoint, is focus on how much a participant needs to be saving to accomplish their goals. Typically, we tell them they need to save eight to ten times their salary, because they will live off about 80% of their pre-retirement income when they retire. This money has to last them 20 to 25 years. So again, getting them to start saving and then try to increase the amount saved each year is going to be important in reaching those retirement goals.

You also want to talk to participants about Social Security. Many people believe Social Security is going to be a large portion of their income at retirement.  During our retirement meetings, we show them an estimate of the percentage of their income that will come from Social Security and what percentage has to be made from their private sources.

I think it is important to educate participants along the way to ensure that they are not surprised when they are 65 years old and ask “am I going to have enough to retire?” The last thing we try to incorporate in every one of our meetings is a retirement estimate. That is something we put on the fourth quarter statement for our clients. We calculate a projected retirement income based on their personal contributions, along with their employer contributions.  When you look at this calculation each year, if the number has gone up, you’re doing the right things.  That number is what you can expect to live on, along with social security, during retirement.

Question: Tell us about the different kind of structures that could be in place for a physician practice.

Answer: Typically, the ultimate goal is to try to get as much of a contribution into the physician’s account as possible while attempting to minimize the required contribution to the rest of the staff. There are different ways you can structure a plan depending on which safe harbor contributions you choose to make. The two options we see most often include a 3% non-elective contribution, which means that every participant would receive a fully-vested 3% contribution based on their compensation or a basic safe harbor match of 100% on the first 3% they defer and 50% on the next 2% deferred. Which scenario a practice chooses depends on the ultimate goal of the practice. If the practice is going to make a profit-sharing contribution in addition to the safe harbor contribution, then choosing the 3% safe harbor, non-elective contribution is often the better approach.  This is because this 3% contribution counts towards satisfying the practice’s minimum required non-elective contribution that each eligible participant is required receive in a cross-tested profit-sharing plan. The two most common types of physician practice profit sharing plan designs are the aforementioned cross-tested design or the integrated design. Depending on the age of the physicians and their ultimate goal, we can look at each plan design to ensure the maximum benefit at the lowest cost.

Question: What can Physicians do to ensure they have the right plan? 

Answer: We recommend that you review your plan or have a professional assist, periodically, to better understand your fees structure, plan design and investments.  When it comes to fees, it can be difficult to understand where they’re coming from, what they’re for and how the they are paid.  In particular, understanding the different ways that fees are structured can reveal some areas for cost savings.

We suggest you find out how your plan advisors are compensated.  They’re often compensated through a 12b-1 agreement or some type of commission-based arrangement within the fund options. Also, it’s a good idea to find out if there is an amount contributed towards record keeping.  We offer plan assessments where we look at your plan’s design, fees, investment diversification, investment performance and your investment policy statement.  We want to make sure your plan is appropriately designed to get the maximum benefit. During our assessments, we typically find that people determine what they like and don’t like about the plan, and from there, we give them recommendations. The goal is just to understand your plan better.

Article contributed by Jack Adams, Asset Management Member & Retirement Plan Consultant. Warren Averett is an official Gold Partner with the Medical Association.

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