Attend the only Medicare Advantage Conference Designed for the MAO Legal Community
The Medicare Advantage program is making headlines.
This government program—an alternative to traditional Medicare—is experiencing immense growth, as well as heightened scrutiny. In the last year, there have been fraud and abuse allegations, findings of coverage and prior authorization denials, and increased costs to tax payers. However, there have been other findings that these plans do not deny coverage or care anymore often than traditional Medicare and that they are good examples of value based models.
It’s critical that MAOs who administer the program stay abreast of the latest legal and regulatory developments, and remain hypervigilant about potential fraud, waste, and abuse related risks.
Join us at ACI’s Legal, Regulatory, and Compliance Summit on Medicare Advantage on October 12–13 for a deep dive into new and impending regulations from CMS, analyses of big impact cases, forward-thinking conversations about the strategies, that will protect your organization, and best practices for both administration and compliance.
Featured sessions will include:
ç Special Q&A with the OIG and DOJ Analyses of the Most Notable Fraud and Abuse Cases of the Year: The Biggest Wins, Losses, and Lessons Learned for MAO Case Strategies
ç A Think Tank on Developing Successful Value-Based Arrangements for MAOs: Navigating Safe Harbors and Avoiding Stark Law, and AKS Violations in the Payor-Provider Relationship
ç A Special Focus on Prior Authorization Findings: Emerging Trends Following the OIG Report
WHO YOU WILL MEET
In-House Counsel and Business Executives from Medicare Advantage Organizations, and Insurance Companies specializing in:
» Litigation
Risk management
Claims/Strategic payments
Payor relations disputes
Medicare Compliance
Audits
Regulatory Affairs
Outside Counsel specializing in:
Health Plans and Government Programs
Regulatory affairs and compliance
Health litigation
Medicare Advantage litigation
Medicare Advantage contracting
Payor disputes
8:45
Co-Chairs’ Opening Remarks
microphone-alt Karen Lam, Senior Counsel, Kaiser Permanente
Elizabeth Lippincott, Managing Member, Strategic Health Law
9:00
Medicare Advantage Outlook for 2023
microphone-alt Molly T. Turco, Senior Advisor, Center for Medicare, Centers for Medicare & Medicaid (CMS)
9:45
Biden Briefing for MAOs: Examining the Administration’s Health Policy Priorities and Preparing for Stronger Regulatory Oversight and Enforcement
microphone-alt 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.
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
microphone-alt Karen Lam, Senior Counsel, Kaiser Permanente
Marguerita Brunson Sims, Senior Counsel, CareSource
Steven Hamilton, Partner, Reed Smith
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
microphone-alt 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
microphone-alt Dorothy DeAngelis, Senior Managing Director, Ankura
Kathy Roe, Attorney & Co-Founder, Health Law Consultancy
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:
Analyzing the Most Notable Fraud and Abuse Cases of the Year: The Biggest Wins, Losses and Lessons Learned for MAO Case Strategies
microphone-alt Rachel Alexander, Partner, Wiley
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
microphone-alt Deborah Marine, JD, CHC, Healthcare Compliance Executive, SummaCare
Eli Burriss, Partner, Katten Muchin Rosenman LLP
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
microphone-alt Elizabeth Lippincott, Managing Member, 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
microphone-alt Xavier Baker, Principal, Groom Law
Janice 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
microphone-alt 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
microphone-alt Randi Seigel, Partner, Manatt, Phelps & Phillips, LLP
Erica Kraus, Partner, SheppardMullin
• Overview of potential VBP arrangements between payors-providers and considerations when choosing a VBP model
• Understanding and using VBP Anti-Kickback Safe Harbors
• Other regulatory considerations related to VBP arrangements
• Anticipating and prospectively addressing areas of dispute in plan-provider contracts
3:30
Exploring Best Practices for MAO’s to Ensure HCC Submission Accuracy
microphone-alt Jeff De Los Reyes, Senior Vice President, Healthcare Analytics and Risk Adjustment Solutions, Gorman Health Group
Assessing what’s working and what’s not as it relates to how SDOH contracts and payment This session will examine best practices to help MAO’s ensure the accuracy of their submissions for risk adjustment to CMS.
The presentation will cover:
• How to proactively identify what may have a higher likelihood of not being documented in the medical record
» Importance of vendor oversight and QA
» Submission process to create/delete transactions
Analyzing CMS response files to ensure that HCC deletes are being accepted
4:15 Conference Concludes
