Medicare advantage program is a government scheme which is applied on the basis of disability or age. To begin with, it covers almost one-third of the whole USA. These plans are regional and mostly offered by insurance companies in the states. These plans basically depend on the factor of variability. It is a must that these plans should cover the traditional Medicare cover. There is also a high chance of these programs being expanded from basic coverage where other services also added. Those services can be dental, drugs, eyeglasses along with the possibility of venturing into medical and surgical services. The costs of these programs can be less than that of traditional one.

There are certain challenges with the healthcare providers regarding Medical Advantage (MA) programs. These issues can be faced by various providers like physicians, hospitals, skilled nurses, and others like home healthcare providers. Coding, billing and reimbursement activities are many a times governed by the contract between the provider and the MA program. This happens when a given provider is a part of the network.

In certain scenarios, there can be a claim filed by a healthcare provider with a MA plan. This plan can be filed across the country where there is no relation between the provider and the MA plan. 

Three different perspectives are discussed in this workshop:

1. Medicare beneficiary of the MA plans,
2. Providers coding, billing and reimbursement relative to MA plans,
3. Medicare’s relationship and compliance related to MA organizations.

The provider relationship, especially the physicians and hospitals, are given more importance in this program. A claim can be arbitrated under a traditional Medicare rule if it filed by a healthcare provider who is not a part of the MA plan’s network. Sometimes, claims can be adjudicated and paid in hazy way if there is variability in the coverage and medical policies.

Possible expansion of Tele health benefits as listed in the 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 a MA program?
• What kind of appeal processes is 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 Tele health services for MA programs?

Webinar Objectives: 

1. To understand Medicare Advantage programs work.
2. To appreciate the different forms and formats of MA programs.
3. To appreciate why the MA programs are so popular with Medicare beneficiaries.
4. To understand how physicians, hospitals and other healthcare providers contract with and become part of networks.
5. To appreciate the process of filing claims to MA programs with which the provider has not relationship.
6. To understand how claims are adjudicated and payment is made for both contracted and non-contracted situations.
7. To appreciate the appeals process when there are coverage and/or payment disagreements.
8. To understand how the Medicare program views Medicare Advantage.
9. To explore compliance issues surrounding payment to MA organizations.
10. To review expansion of Tele health services for MA programs.

Agenda of the session: 

1. Medicare Advantage Overview
   • How The MA Programs Work
   • Different Kinds of MA Programs
   • How Payment Is Made
   • Contracted Providers
   • Risk Adjustment
2. Medicare Beneficiaries and MA Programs
   • Coverage Concerns
   • Hospice Coverage
   • Cost-Benefit Analysis
   • MA Program Termination
3. 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 Coverage
4. Medicare Perspective With MA Programs
   • Risk Adjustment Process
   • Payment by Medicare to MA Programs
   • Compliance Concerns and Audits
   • Expansion of Tele health for MA Programs
   • RAC Involvement
5. Sources for Further Information.

Prerequisites for Participating:  General knowledge of healthcare providers including physicians, clinics, and hospitals.

Suggested Attendees:  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, and Internal Auditors.