Medicare Advantage

Registration and Continental Breakfast Served

Co-Chairs’ Opening Remarks

Karen Y. Lam
Senior Counsel, Medicare, Government Programs
Kaiser Permanente

Annie Shieh
Sr. Director of Compliance
Bright Health Group

Elizabeth Lippincott
Managing Member
Strategic Health Law

In Conversation with HHS-OIG: Identifying FWA Risk areas for MA Plans and Opportunities to Improve Compliance

Carolyn Kapustij
Senior Advisor
HHS Office of Inspector General

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

Part D Primer for MA Plans: Preparing for the Redesign Under the Inflation Reduction Act

Melissa Wong
Partner
Holland & Knight LLP

Kathleen Dixon Jaquish
Counsel
BlueCross BlueShield of Tennessee, Inc.

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

Morning Coffee Break

CMS Audit Readiness: How to Set Your MAO Up for Success in the Year Ahead

Teresa Mason
Member of the Firm
Epstein Becker & Green P.C.

Kanika Sabor
Managing Director
Ankura

• 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

Navigating New Limits to the Use of Prior Authorization in Medicare Advantage

Elizabeth Lippincott
Managing Member
Strategic Health Law

Anne Crawford
Senior Vice President, Compliance Solutions
ATTAC Consulting Group (ACG)

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

Networking Luncheon

Special Focus on Enforcement in Medicare Advantage

Emerging Enforcement and Investigation Trends in Medicare Advantage

Lindsey B. Fetzer
Partner
Bass, Berry & Sims

Julie Nielsen
Managing Director
Berkeley Research Group LLC

• 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

Conducting Internal Investigations – Special Considerations for MAOs

Kelly Kappes
Senior Associate General Counsel
Elevance Health

Benjamin Singer
Partner
O’Melveny & Myers LLP

Lori Frey Wells
Staff Vice President, Medicare Compliance
Elevance Health

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)

Afternoon Networking and Refreshment Break

A Technical Briefing on the New MA Star Ratings Methodology and Projected Impact on Plans

Cherié K Shortridge
Senior Advisor
Healthmine

• 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

Developing a Post PHE Transition Plan for Your MAO

Erin Wessling
SVP and Chief Counsel, Commercial, Government Business and Litigation
Cigna

Tara Dwyer
Member
Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C.

• 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

Cocktail Reception Sponsored by BRG

Registration Opens and Continental Breakfast

Co-Chairs’ Opening Remarks

Karen Y. Lam
Senior Counsel, Medicare, Government Programs
Kaiser Permanente

Annie Shieh
Sr. Director of Compliance
Bright Health Group

Elizabeth Lippincott
Managing Member
Strategic Health Law

Keynote

Value-Based Insurance Design (VBID): The Future State of Healthcare Service Delivery

Sibel Ozcelik, ML, MS
Acting Director, Division of Health Plan Innovation, Seamless Care Models Group
CMS Innovation Center

CMS is testing MA health plan innovations aimed reducing program costs and improving the quality of care being delivered to enrollees.

In Calendar Year (CY) 2024, the VBID Model will test flexibilities for select enrollees by offering certain supplemental benefits, including FDA-approved devices, disease state management programs, reductions in cost-sharing, Part C and D rewards and incentives programs, and a hospice benefit.

This session will examine how the model has been performing to date and the implications for plans and patients moving forward.

Payor-Provider Integration and Collaboration: Future Opportunities and Key Legal Risks for MAOs to Consider

Jennifer Kildea Dewane
Vice President & Counsel, Government Business Division
Elevance Health

Steven Hamilton
Partner
Reed Smith LLP

• Analyzing the different types of partnerships that are being formed between plans, providers and other entities
• Pinpointing legal risks and diligence considerations for MAOs
• Addressing legal risks with provider marketing and patient recruitment
• Fine-tuning MAO-provider contracts
• Addressing physician incentive plan requirements and limitations
• Assessing the impact on shared savings and other compensation arrangements on bids etc…
• Navigating AKS and relevant safe harbors
• Key considerations for the future integration and exclusive arrangements

Morning Coffee Break

Panel & Interactive Discussion

Perspectives on Change Management, Compliance and Business Best Practices for the New MA Landscape

Annie Shieh
Sr. Director of Compliance
Bright Health Group

Ken Nuñez, MBA, CHC
Chief Compliance Officer
Provider Partners Management Services

• Sharing best practices to operationalize new requirements
• Communicating with regulators when guidance is unclear to obtain clarification of expectations
• Partnering with the business for successful compliance outcomes

Behavioral Health in Medicare Advantage: Improving Access to Services to Meet Strengthened Network Adequacy Requirements

Xavier Baker
Principal
Groom Law

• Ensuring adequate access to additional behavioral health specialty types
• Examining how telehealth can be used to meet requirements
• Establishing programs to close the equity gap
• Exploring prior authorization limitations

Networking Luncheon

AI and Algorithms Meet Medicare Advantage: Identifying and Managing Risks to Gain Benefits

Kevin Feder
Partner
O’Melveny & Myers LLP

Kathy Roe
Attorney & Co-Founder
Health Law Consultancy

• Summarizing the promise and power of AI and algorithms for MAOs
• Examining Congressional concerns with AI and algorithm use by MAOs and their FDRs
• Reviewing litigant complaints about AI and algorithm use by or on behalf of MAOs and other payers
• Exploring Federal agency considerations for AI and algorithm use by MAOs and their FDRs
• Extracting insight from NAIC action on AI and algorithm use by insurance issuers
• Managing compliance risks from evolving AI and algorithm use by MAOs and their FDRs

Afternoon Networking and Refreshment Break

Avoiding Medicare Advantage Marketing Missteps: Top Takeaways from Real-World Examples and Best Practices for Third-Party Oversight

Jill Pepe MA
PMP Health Plan Services Senior Consultant
BluePeak Advisors

• Reviewing the latest changes to marketing rules for the Medicare Advantage program
• Determining what should be included in materials and what is prohibited under the reformed regulations
• Developing third-party training and oversight program to ensure compliance with regulations and alignment with MAO expectations
• Using examples of marketing and communications materials to identify problematic language, and tactics
• Examining the current state of oversight and enforcement in marketing and how that may evolve

Planning for the Future of Integrated Care: Key Considerations for MAOs in an Evolving D-SNP Landscape

Mike Cheek
President and CEO
SNP Alliance

A bipartisan group of Senators led by Bill Cassidy recently collected feedback on the coordination of care for dually eligible populations.

Draft legislation aimed at further integrating care for dual eligible populations is being circulated. This session will:

• Assess current barriers to integration
• Examine what is being proposed in the bipartisan legislation being proposed
• Anticipate potential operational considerations for MAOs

Conference Concludes