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Day 1 - Wednesday, October 12, 2022

8:45
Co-Chairs’ Opening Remarks
9:00

Biden Briefing for MAOs

Examining the Administration’s Health Policy Priorities and Preparing for Stronger Regulatory Oversight and Enforcement
9:30

Keynote

CMS Medicare Advantage Outlook for 2023
10:15
Morning Coffee Break
10:30

Emerging from COVID-19

Analyzing the Impact of Public Health Emergency Orders on the MA System and Preparing for the Aftermath
11:15

Medical Loss Ratio Calculations and Reporting

How Bolster Compliance and Avoid Costly Penalties
12:00
Networking Luncheon
1:00
Understanding the Implications of the OIG’s Prior Authorization Report for Medicare Advantage
1:45

Staying Competitive and Compliant:

How to Set Your MA Marketing and Communications Strategy Up for Success
2:30
Refreshment Break
2:45

Serving Dual-Eligible Populations

Navigating State and Federal Regulations in the Coordination of Care
3:30
Star Ratings 2023 and Beyond: Examining the Industry Landscape and Forecasting the Future for MAOs
4:30
Day One Concludes

Cocktail Reception Sponsored by
BRG

Day 2 - Thursday, October 13, 2022

8:30
Co-Chairs’ Opening Remarks
8:45
Examining What’s Trending in Medicare Advantage Oversight and Enforcement
9:30

Analyzing the Most Notable Fraud and Abuse Cases of the Year

The Biggest Wins, Losses and Lessons Learned for MAO Case Strategies
10:00
Morning Coffee Break
10:15

Qui Tam Actions

What Recent Cases Indicate about How MAOs Should Approach Whistleblower Complaints
11:00

Risk Adjustment

Forecasting Future Enforcement and the Implications for the Compliance and Legal Landscape
12:00
Networking Luncheon
1:00

Chart Reviews and Health Risk Assessments

Top Dos and Don’ts for MAOs When Collecting Diagnosis Data for Risk Scores
1:45

Private Equity and Medicare Advantage Investments

Analyzing Trends and Critical Legal Risk Considerations
2:30
Refreshment Break
2:45

Developing Successful Value-Based Arrangements for MAOs

Navigating Safe Harbors and Avoiding Stark Law, and AKS Violations in the Payor-Provider Relationship
3:30

Innovative Approaches to Addressing Social Determinants of Health

How to Structure Programs to Improve Plan Member Health, Reduce Costs and Manage Risks
4:15
Conference Concludes

Post-Conference Workshop

Workshop — Medicare Advantage Risk Adjustment Boot Camp: Deep Dive into Critical Legal, and Technical Concepts

Oct 14, 2022 9:00am – 12:30pm

Speakers

Jeff De Los Reyes
Senior Vice President, Healthcare Analytics and Risk Adjustment Solutions
Gorman Health Group

Day 1 - Wednesday, October 12, 2022

8:45
Co-Chairs’ Opening Remarks

Karen Lam
Senior Counsel
Kaiser Permanente

Elizabeth Lippincott
Partner
Strategic Health Law

9:00

Biden Briefing for MAOs

Examining the Administration’s Health Policy Priorities and Preparing for Stronger Regulatory Oversight and Enforcement

Ankur Goel
Partner
McDermott Will & Emery

Join our speakers for an in-depth discussion of what’s percolating on the Hill.

Learn how this Administration’s policies are influencing Medicare Part C plans, and analyze new and impeding regulations, including the CMS policy and technical changes set out in the Medicare Advantage and Part D final rule. Our panel will provide an analysis of the implications of these regulations and initiatives for MAOs, as well as provide proactive steps that will help organizations prepare for these changes.

9:30

Keynote

CMS Medicare Advantage Outlook for 2023
10:15
Morning Coffee Break
10:30

Emerging from COVID-19

Analyzing the Impact of Public Health Emergency Orders on the MA System and Preparing for the Aftermath

Steven Hamilton
Partner
Reed Smith LLP

Karen Lam
Senior Counsel
Kaiser Permanente

Marguerita Brunson Sims
Senior Counsel
CareSource

Moderator:

Lou Patalano
Of Counsel
K&L Gates LLP

  • Examining how Medicare coverage and reimbursement changed during the COVID-19 Public Health Emergency, how it’s still evolving, and its particular implications for MA plans
    • Determining what’s covered, and what’s not from at home tests to telehealth services as we move from pandemic to endemic
    • Understanding developments in mental and behavioral health post-COVID
  • Assessing how the addition of telehealth diagnoses codes will impact the business and risk adjustment programs
    • Anticipating future uptake: assessing utilization by the senior population post-pandemic
  • How to manage and adjust the roll back of certain services provided  to beneficiaries during the PHE
  • Exploring pandemic related fraud and abuse risks and enforcement actions relative to Medicare and MA programs
    • Forecasting future enforcement actions for overpayment
    • Identifying what plans can do as we emerge from the pandemic to ensure data accuracy and overall compliance

11:15

Medical Loss Ratio Calculations and Reporting

How Bolster Compliance and Avoid Costly Penalties

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

Alex Oliphant
Director
Berkely Research Group LLC

  • Defining Medical Loss Ratio (MLR)
    • Examining MLR reporting and enforcement historically, and the risks associated with MLR submissions
  • Examining data reporting considerations for MLR data submissions
  • Assessing legal risks posed when submitting MLR data and how to mitigate those risks

12:00
Networking Luncheon
1:00
Understanding the Implications of the OIG’s Prior Authorization Report for Medicare Advantage

Dorothy DeAngelis
Senior Managing Director
Ankura

The Department of Human and Health Services Office of Inspector General (OIG)  released a report this year highlighting delayed and denied access to care by Medicare Advantage organizations in instances where coverage requirements were met. The HHS OIG has recommended that CMS issue guidance on specific clinical criteria, and audit protocols to prevent these occurrences. This session will examine the implications of the report for MAOs and how to proactively strengthen compliance practices in response. Points of discussion include:

  • Use of internal plan criteria to supplement Original Medicare policies
  • Performing oversight of internal operations and vendors and providers performing prior authorization
  • Analysis of appeals outcomes and appropriate follow-up for high overturn rates
  • How to strengthen your compliance program for first tier, downstream and related entities: key policy considerations and action items for MAOs
  • Enhancing FDR monitoring and auditing best practices

1:45

Staying Competitive and Compliant:

How to Set Your MA Marketing and Communications Strategy Up for Success

Archana Rajendra
Senior Counsel
Vice President, Deputy General Counsel, Health Alliance Plan, Henry Ford Health

Melissa Wong
Partner
Holland & Knight LLP

  • Review of Third-Party Marketing Organization (TPMO) requirements in April 2022 CMS final rule
  • Evaluating key risk areas, and applicable laws, including AKS, State Laws, fraud, and abuse
  • Complying with technical and content requirements for different  marketing materials
    • Identifying what’s new, what has changed, and how to align your compliance program
    • Guidance on the parameters for promotional activities, and nominal gifts
  • Examining the lesser-known pitfalls when marketing to and communicating with members using hypothetical examples
  • Practical insights on developing a successful communications strategy that meets compliance requirements and protects current and prospective members

2:30
Refreshment Break
2:45

Serving Dual-Eligible Populations

Navigating State and Federal Regulations in the Coordination of Care

Will Dede
Associate Director
Health Policy, SNP Alliance

  • Primer on Medicare-Medicaid plans (MMP,) including an examination of integrated care enrollment trends, and contracting requirements
    • What’s involved in contracting at the state and federal level
  • Differentiating between HIDE and FIDE and standalone D-SNP contracts
  • Examining new and updated provisions for SNPs set out by CMS
    • Guidance on maximum out-of-pocket limits for D-SNPs
    • Impact of April 2022 CMS final rule

3:30
Star Ratings 2023 and Beyond: Examining the Industry Landscape and Forecasting the Future for MAOs

Taylor Mussen
Associate Principal
Avalere Health

  • Explore an overview of the 2023 Star Ratings for Medicare Advantage plans
  • Understand the key takeaways and measurement changes from the 2023 Star Ratings
  • Learn more about the sweeping program and measure changes
  • Learn what’s important for plans to know for Star Ratings success

4:30
Day One Concludes

Cocktail Reception Sponsored by
BRG

Day 2 - Thursday, October 13, 2022

8:30
Co-Chairs’ Opening Remarks
8:45
Examining What’s Trending in Medicare Advantage Oversight and Enforcement

Carolyn Kapustij
Senior Advisor
HHS Office of Inspector General

David M. Coriell
Assistant U.S. Attorney Western District of New York
U.S. Department of Justice

In this not to be missed session, key government officials will offer MAOs critically important insights into the risk areas on their radar. Join us for a discussion of enforcement trends and key takeaways from targeted audits.  Points of discussion include:

  • OIG priorities for 2023
    • OIG audit process— what to expect procedurally, and what recent findings reveal
    • Best practices to detect, prevent and rectify non-compliance
    • How to approach overpayments
  • Lessons learned from recent enforcement actions
    • Rundown of notable cases and the implications for MAOs
    • New and emerging areas of focus as it relates to fraud, waste, and abuse

9:30

Analyzing the Most Notable Fraud and Abuse Cases of the Year

The Biggest Wins, Losses and Lessons Learned for MAO Case Strategies

Rachel Alexander
Partner
Wiley Rein LLP

Benjamin McCoy
Partner
Fox Rothschild LLP

  • Analysis of noteworthy Part C cases of the year
    • Identifying types of fraud targeted in these cases, including falsified diagnoses, unnecessary treatment, and upcoding
    • Forecasting future FCA cases involving COVID-19 relief programs
    • Examining defenses put forward by payors and providers
      • Materiality and objective falsity standards in FCA Litigation
  • What measures can MAOs take to avoid scrutiny?

10:00
Morning Coffee Break
10:15

Qui Tam Actions

What Recent Cases Indicate about How MAOs Should Approach Whistleblower Complaints

Eli Burriss
Partner
Katten Muchin Rosenman LLP

Deborah Marine, JD, CHC
Chief Compliance Officer
Health Plan Operations, SummaCare

Joseph Martin
General Counsel
Clover Health

  • Examining key recent qui tam actions impacting MA programs How to prepare for and respond to internal whistleblowers?
    • How to design your compliance program to mitigate risk
      • Key considerations for whistleblower policies and procedures for handling complaints

11:00

Risk Adjustment

Forecasting Future Enforcement and the Implications for the Compliance and Legal Landscape

Elizabeth Lippincott
Partner
Strategic Health Law

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

Julie Nielsen
Managing Director
Berkeley Research Group LLC

Risk adjustment is being heavily scrutinized by government agencies, in an effort to prevent and address fraud, waste and abuse in the administration the Medicare Advantage program. For MAOs, navigating the complexities of risk adjustment to ensure data accuracy and compliance is of the utmost importance—as a failure to do so can lead to costly consequences. This session will examine the influence of the legal landscape, key oversight channels, and compliance best practices. 

  • Analysis of oversight channels
    • CMS RADV audits
    • OIG Targeted and RADV-like audits
    • Whistleblower FCA litigation
    • DOJ perspective on risk adjustment as revealed in FCA litigation
  • Insights on the relevance of actuarial equivalence and current applications in law
    • Overpayment rule
  • Examining how plans calculate bid rates and risk score projections
  • Forecasting potential outcomes for the CMS’ proposed rule and the implications for MAOs
    • Identifying calculation modifications and how to align internal processes to ensure compliance
    • How does it ultimately impact plans who are selected for RADV audit
  • Developing compliance oversight of risk adjustment in the absence of cohesive guidance
  • Determining what immediate corrective actions can be taken when FWA is detected

12:00
Networking Luncheon
1:00

Chart Reviews and Health Risk Assessments

Top Dos and Don’ts for MAOs When Collecting Diagnosis Data for Risk Scores

Xavier Baker
Principal
Groom Law

Janice H. Ziegler
Partner
Dentons US LLP

The OIG recently reported that Medicare Advantage organizations may be using chart reviews and health risk assessments to boost risk scores and increase capitation payments from CMS.
This session will focus on the parameters of use, and risk mitigation measures for MAOs from a legal, and compliance perspective. 

  • Overview and analysis of OIG report and subsequent recommendations for stronger oversight
  • Determining your organization’s risk tolerance in using tools like chart reviews, health assessments, wellness visits, and datamining to improve beneficiary health insights and the accuracy of risk scores
  • How to integrate risk adjustment and quality improvement programs to limit legal risk and improve care
  • Understanding the nuances of coding requirements for risk-adjustment based reimbursement
    • Assessing chart review programs to ensure diagnosis coding aligns with regulations and is sufficiently documented
  • Examining the litigation landscape
    • Key takeaways from notable Qui Tam cases

1:45

Private Equity and Medicare Advantage Investments

Analyzing Trends and Critical Legal Risk Considerations

Devin A. Cohen
Partner
Ropes & Gray LLP

Private Equity and industry investment in Medicare Advantage have struggled to keep pace with the program’s rapid growth.  Particularly considering heightened government scrutiny on program integrity, this presentation will focus on investment considerations and trends as investors navigate MAO, FDR, and related partnership opportunities.
Discussion will focus on:

  • RADV, medical necessity/documentation
  • Risk sharing, beneficiary inducement, compliance infrastructure, and related diligence considerations for evolving Medicare Advantage stakeholders
  • Case studies from recent enforcement actions to predict forthcoming enforcement trends
  • Select case studies from recent enforcement actions to predict forthcoming enforcement trends

2:30
Refreshment Break
2:45

Developing Successful Value-Based Arrangements for MAOs

Navigating Safe Harbors and Avoiding Stark Law, and AKS Violations in the Payor-Provider Relationship

Randi Seigel
Partner
Manatt, Phelps & Phillips, LLP

Erica Kraus
Partner
SheppardMullin

  • Overview of CMS MA regulatory requirements
  • Navigating the OIG and CMS safe harbors and exceptions for value-based arrangements
    • Examining provisions for physician incentive plans
  • Analyzing key risks and benefits of value-based arrangements
    • Anticipating where payor-provider disputes can arise
  • How will your organization decide where to fall on the spectrum of risk tolerance?

3:30

Innovative Approaches to Addressing Social Determinants of Health

How to Structure Programs to Improve Plan Member Health, Reduce Costs and Manage Risks

  • How to identify what supplementary benefits members need to stay healthy
  • Assessing what’s working and what’s not as it relates to:
    • How SDOH contracts and payment models are structured
      • Risk areas for MAOs
    • Program design and supplementary benefits being offered, medical and non-medical such as transportation
      • Determining the parameters for the program—who is eligible?
  • Overview of CMS guidelines and initiatives aimed at addressing social drivers of health
    • Forecasting how drivers of health could potentially factor into risk adjustment payments and stars determinations in the future
  • How to identify what supplementary benefits members need to stay healthy
  • Establishing key metrics and a program for monitoring health outcomes tied to SDOH programs and supplemental benefits
  • Practical insights on barriers to implementation and how to overcome them
  • Assessing coverage considerations for dual eligible populations in light of social determinants of health

4:15
Conference Concludes

Workshop — Medicare Advantage Risk Adjustment Boot Camp: Deep Dive into Critical Legal, and Technical Concepts

Oct 14, 2022 9:00am – 12:30pm

Jeff De Los Reyes
Senior Vice President, Healthcare Analytics and Risk Adjustment Solutions
Gorman Health Group

What is it about?

This workshop is designed specifically for MAO legal and compliance professionals who want to deepen their technical knowledge of risk adjustment methodologies, and the related coding, compliance, and legal risks. Workshop leaders will provide insights on how risk adjustment is evolving, the influence of the litigation landscape, and how to bolster internal oversight, to mitigate risks.

  • Examining proposed changes to the risk adjustment model, how it has evolved over time and how these technical changes will impact the business
    • Anticipating potential future changes based on current litigation
  • Acquiring a deeper understanding of how CMS extrapolates audit findings
    • Anticipating the financial impact on the organization
    • Hypothetical examples demonstrating risk score calculations and reporting requirements
  • Identifying opportunities to leverage data to improve compliance and mitigate future risks
    • When to self-disclose
  • Developing effective compliance oversight of risk adjustment activities
  • Conducting an internal mock audit
    • Practical insights on how to avoid the lesser-known pitfalls through lessons learned from past audits
    • Overview of the appeal process