Medicare Advantage

Join Carolyn Kapustij, Senior Advisor, HHS Office of Inspector General for a focused presentation– on the risks being identified, and targeted by the OIG—followed by an interactive Q&A.

In this session hear directly from the HHS-OIG on:

• Examining top priorities for 2024
• Identifying emerging areas of risk for MAOs
• Applying key takeaways from recent audits

CMS will publish the first 10 Medicare drugs selected under the Medicare Drug Price Negotiation Program established in the Inflation Reduction Act, this year. This workshop will provide an in-depth overview of what’s included in the IRA and how it will impact Part D plans moving forward. Delve into the regulations, mechanics and implementation challenges associated with:

• Key provisions in the Inflation Reduction Act including Medicare drug price negotiation program Part D Redesign: Medicare Part D brand name drug costs and spending caps
• Premium benchmark stabilization vs. actual Part D plan premiums
• Projecting the impact on overall plan costs Examining opportunities to mitigate the impact through formulary design and utilization management
• Part D “smoothing” of cost sharing and operational challenges

• Understanding what the latest changes to the RADV model mean for MA plans
• Overview of the 2023 program audit process and critical steps for audit preparation
• Establishing legal and compliance obligations
• Utilizing data analytics to pinpoint compliance gaps
• Rectifying errors with a corrective action plan

Growing concerns over delays and denials of medical treatment have prompted reforms to MAO prior authorization practices.

CMS 2024 policy and technical changes are intended to streamline the process and increase transparency of the metrics being used by plans in for coverage determinations.

This session will cover notable changes, legal and business considerations for MAOs including:

• Overview of new limits on prior authorization use
• Coverage determination rules
• CMS Two Midnight Rule for inpatient services
• Ensuring plan policies comply with LCDS/NCDs
• Examining the current and future state of gold carding laws and plan programs
• Creating a utilization management committee

• Assessing the current enforcement landscape for Medicare Advantage plans
• Top takeaways from recent FCA cases involving Medicare Advantage plans
• Latest Qui Tam whistleblower claims
• Tracking trends in the types of fraud targeted in these cases, including falsified diagnoses, unnecessary treatment, and upcoding
• Anticipating future FCA activity in Medicare Advantage
• Identifying opportunities to strengthen compliance, and training to avoid litigation and regulatory scrutiny as an MAO

This session will provide an overview of key strategies and lessons for MAOs conducting internal investigations. Key topics include:

• Exploring strategies for identifying possible instances of non-compliance
• Utilizing best practices for in-house investigations and identifying when to engage outside counsel
• Protecting the privilege – key developments in case law affecting privilege considerations
• Best practices for avoiding waiver pitfalls
• Examining complexities impacting MAOs (e.g., joint defense agreements and disclosure to third parties)

• Examining the latest MA and Star Ratings program changes
• Technical updates from the Rate Announcement and Final Rule
• Understanding the impact of health equity measures
• Exploring industry developments impacting Star Ratings success

• How to manage certain services provided to beneficiaries now that the PHE has ended
• Identifying what plans can do as we emerge from the pandemic to ensure data accuracy and overall compliance
• Assessing how the addition of telehealth diagnoses codes will impact the business and risk adjustment programs