How to hold Medicare Advantage plans accountable

Editor’s note: Kimberly A. Hoy, JD, CPC, will present “Holding Medicare Advantage Plans Accountable for Coverage Decisions” on day one of the 2024 Revenue Integrity Symposium, which will take place September 12–13 in Oak Brook, Illinois. Hoy is the director of Medicare and compliance for HCPro LLC in Chicago, Illinois. Learn more about the event by downloading the brochure. Use NAHRI’s justification letter template as a guide to gain your organization’s support for attending.

Q: What challenge does your session help address? How?

Hoy: Providers have struggled with Medicare Advantage plans for a while now and CMS has finally given us rules to hold them accountable. I want to give providers the information they need to ask the right questions of their plans and push back where necessary to ensure services are covered for their patients and they get fair compensation for them.

Q: What's one of the key pieces of information you would like people to take away from your session?

Hoy: I’ll be discussing prior authorization rules and limitations on denials after payment, which should curtail the egregious take backs we’ve been seeing post payment.

Q: What are you most excited about for this year's conference?

Hoy: There’s lots of new speakers this year so I’m excited to see all the new content. I’m also excited to see all my colleagues in person to catch up and, of course, make new connections.

Q: What's a great piece of advice you’d like to give people about your session topic?

Hoy: My session will go over regulations applicable to Medicare Advantage plans, but it will be up to providers to hold their plans accountable. Providers can draw on the regulatory requirements from my session to question the plans and shouldn’t be afraid to build some of these protections into their contracts to ensure all parties are on the same page.