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 is 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, 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 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 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 not 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 expansion of telehealth services for MA programs.
Areas Covered in 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
- Managed Care Analysts
- Compliance Officers
- Compliance Analysts
- RAC Coordinators
- Clinical Directors/Managers
- Physicians, Practitioners
- Information Technology Personnel
- Computer Analysts
- Health Information Management Personnel
- Chargemaster Coordinators
- Revenue Cycle Specialists
- Internal Auditors
About the Presenter:
Duane C. Abbey, PhD, CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc., a consulting firm specializing in healthcare 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. Dr. Abbey works extensively in all areas relating to compliance reviews, coding, billing and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals and physicians based clinics.
In addition to his consulting practice, Dr. Abbey also teaches workshops and makes presentations on a regular basis. He has taught at the University level and speaks nationally. He is a regular presenter for hospital associations, medical societies, Boards of Trustees and various other organizations and groups. In addition, professional societies such as HFMA use Dr. Abbey’s services to present seminars and workshops.
Dr. Abbey is a nationally recognized expert in payment systems. A special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications and/or contracted for his services. Attendees at these seminars over the years have included personnel from hospitals, clinics, integrated delivery systems and multiple consulting firms.
Dr. Abbey is also the author of numerous articles and books including: Compliance for Coding, Billing & Reimbursement, Outpatient Services: Designing, Organizing & Managing Outpatient Resources, ChargeMaster: Review Strategies for Improved Billing and Reimbursement, Ambulatory Patient Group Operations Manual, published by McGraw-Hill and Non-Physician Providers: Guide to Coding, Billing & Reimbursement, Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance, and Emergency Department Coding & Billing: A Guide to Reimbursement & Compliance published.
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