Understanding Medicare Advantage Programs for Physicians and Hospitals

Event Information
Product Format
Prerecorded Event
90 minutes
Product Description

Medicare Advantage Programs for Physicians and Hospitals: Compliance Issues

Approximately one-third of all Medicare beneficiaries are enrolled in various Medicare Advantage (MA) programs. These plans are generally offered by insurance companies and tend to be regional. The key descriptor for these programs in that of variability. Each of these programs must cover what traditional Medicare covers, but they then generally expand from this basic coverage and add services such as dental, drugs, eyeglasses along with possibly expanded coverage for medical and surgical services. In some cases the costs of these programs is less than traditional Medicare.

For MA programs, emphasis is given to provider relationships particularly for physicians and hospitals. If a claim is filed by a healthcare provider that is not part of the MA plan’s network, then the claim is to be adjudicated under the traditional Medicare rules. Given the variability in coverage and medical policies, there can be confusion when claims are adjudicated and paid.

MA programs represent some real challenges for healthcare providers such as physicians, hospitals, skilled nursing, home health among others. In some cases, a given provider will be part of a network or under contract to the given MA plan, and, thus, coding, billing and reimbursement are governed by the contract. In other cases, a given healthcare provider may by filing a claim with an MA plan across the country in which there is no relationship between the MA plan and the provider.

Join this session, where expert speaker Duane C. Abbey, Ph.D., will discuss three different perspectives:

  • Medicare beneficiary to the MA plans
  • Providers coding, billing and reimbursement relative to MA plans
  • Medicare’s relationship and compliance relative to MA organizations

Session Objectives

This session will discuss:

  • How Medicare Advantage programs work
  • Why the MA programs are so popular with Medicare beneficiaries
  • How physicians, hospitals and other healthcare providers contract with and become part of network
  • The process of filing claims to MA programs with which the provider does not have a relationship
  • How claims are adjudicated and payment is made for both contracted and non-contracted situations
  • The appeals process when there are coverage and/or payment disagreements
  • How the Medicare program views Medicare Advantage
  • Compliance issues surrounding payment to MA organizations

Session Highlights

  • What is Medicare Advantage
  • What kinds of services are covered by MA programs
  • Do physicians and hospitals contract with MA organizations
  • How do MA programs pay for services of physicians, hospitals and other healthcare providers
  • What if a physician or hospital is not contracted with a MA program
  • What kind of appeal processes are available when physicians and hospitals disagree on payment or coverage
  • What is this risk adjustment process

Session Agenda

  • Medicare Advantage overview
    • How the MA programs work
    • How payment is made
    • Contracted providers
    • Risk adjustment
  • Medicare beneficiaries and MA programs
    • Coverage concerns
    • Hospice coverage
    • Cost-benefit analysis
    • MA program termination
  • Healthcare provider relations
    • Physicians and hospitals contracting with MA programs
    • Contracted providers filing claims with MA programs
    • Non-contract providers filing claims with MA programs
    • Appeals process for disagreements
    • Claims adjudication and claims payment
    • Primary care versus specialized services
    • Special MA program concerns
      • Hospice
      • Medicare secondary
    • Special coverages
  • Medicare perspective with MA programs
    • Risk adjustment process
    • Payment by Medicare to MA programs
    • Compliance concerns and audits
    • RAC involvement
  • Sources for further information

Who Should Attend

  • Managed care analysts
  • Compliance officers
  • Compliance analysts
  • RAC coordinators
  • Clinical directors/managers
  • Physicians
  • Practitioners
  • Nurses
  • Information technology personnel
  • Computer analysts
  • Health information management personnel
  • Charge master coordinators
  • Revenue cycle specialists
  • Internal auditors

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

Order Below or Call 1-844-384-4744 Today

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
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