Approximately one-third of all Medicare beneficiaries are enrolled in various Medicare Advantage programs. These plans are generally offered by insurance companies and tend to be regional. The key descriptor for these programs is 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 are less than traditional Medicare.
Medicare Advantage (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 between the provider and the MA program. In other cases, a given healthcare provider may be filing a claim with an MA plan across the country in which there is no relationship between the MA plan and the provider.
Three different perspectives are discussed in this workshop:-
- Medicare beneficiary to the MA plans,
- Providers coding, billing, and reimbursement relative to MA plans,
- Medicare’s relationship and compliance relative to MA organizations.
For this program, the 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.
Possible expansion of telehealth benefits as listed on November 1, 2018, Federal Register will also be discussed.
- What is Medicare Advantage?
- What are the different kinds of MA programs?
- Why are Medicare beneficiaries interested in the MA programs?
- 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 an MA program?
- What kind of appeal processes are available when physicians and hospitals disagree on payment or coverage?
- How does Medicare view these MA programs?
- What is this risk adjustment process?
- What kind of compliance issues are there with MA programs?
- How is the CMS expanding telehealth services for MA programs?
- To understand Medicare Advantage programs work.
- To appreciate the different forms and formats of MA programs.
- To appreciate why the MA programs are so popular with Medicare beneficiaries.
- To understand how physicians, hospitals and other healthcare providers contract with and become part of networks.
- To appreciate the process of filing claims to MA programs with which the provider has no relationship.
- To understand how claims are adjudicated and payment is made for both contracted and non-contracted situations.
- To appreciate the appeals process when there are coverage and/or payment disagreements.
- To understand how the Medicare program views Medicare Advantage.
- To explore compliance issues surrounding payment to MA organizations.
- To review the expansion of telehealth services for MA programs.
Agenda of the session:-
- Medicare Advantage Overview
- How The MA Programs Work
- Different Kinds of MA Programs
- 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
- Medicare Secondary
- Special Coverages
- Medicare Perspective With MA Programs
- Risk Adjustment Process
- Payment by Medicare to MA Programs
- Compliance Concerns and Audits
- Expansion of Telehealth for MA Programs
- RAC Involvement
- Sources For Further Information
Prerequisites for Participating:-
General knowledge of healthcare providers including physicians, clinics, and hospitals.
- Managed Care Analysts
- Compliance Officers
- Compliance Analysts
- RAC Coordinators
- Clinical Directors/Managers
- Information Technology Personnel
- Computer Analysts
- Health Information Management Personnel
- Chargemaster Coordinators
- Revenue Cycle Specialists
- Internal Auditors