Understanding Medicare Advantage Programs for Advanced & Intermediate Levels

*This program has the prior approval of AAPC for 1.5 continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

Session Overview

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.

Join expert presenter, Duane C. Abbey, CFP, to understand the three different perspectives that are discussed in this workshop - Medicare beneficiary to the MA plans;  Providers coding, billing and reimbursement relative to MA plans, and  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 and the newest Federal Register will also be discussed.

• What are the different kinds of MA programs? What kinds of services are covered by MA programs?


• Do physicians and hospitals contract with MA organizations? What if a physician or hospital is not contracted with a MA program?


• How do MA programs pay for services of physicians, hospitals and other healthcare providers?


• What kind of appeal processes are available when physicians and hospitals disagree on payment or coverage?


• How does Medicare view these MA programs? Why are Medicare beneficiaries interested in the 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?

Session Objectives

• 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.

Session Agenda

1. Medicare Advantage Overview

• Different MA Programs, How The MA Programs Work


• How Payment Is Made; Risk Adjustment; Contracted Providers

2. Medicare Beneficiaries and MA Programs

• Coverage Concerns


• Hospice Coverage, Special Coverages


• 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

4. 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

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


• Chargemaster Coordinators


• Revenue Cycle Specialists, and Internal Auditors

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

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