The Let’s Talk Compliance podcast series is for healthcare leaders and compliance professionals, as well as providers, suppliers, vendors, and others in the healthcare industry. In each episode, a Foley & Lardner attorney and a PYA advisor discuss a trending compliance topic and address questions they hear most often from clients.
In the August 30 episode, “Medicare Advantage Compliance Enforcement Underway” Jana Kolarik, a Foley Partner, interviews Michael Tuteur, Foley Government Enforcement & Defense Investigations Practice Group, and Valerie Rock, PYA Principal, about Medicare Advantage (MA) compliance and enforcement.
Rock explains why MA compliance is now a trending issue. She says in 2032 the Baby Boomer population will age into MA, which is Part C of Medicare, meaning close to 61% of the overall Medicare population will be participating in the plan. Because of this imminent growth, Medicare is increasing its focus on compliance in Medicare Advantage.
The method of payment in MA is different than with Medicare, Rock explains. “When Medicare is determining how to pay Medicare Advantage, [it’s] based on a risk methodology that has a lot of constructs within it, but it’s really rooted in the complexity of the diagnoses for each patient….[The] underlying theme then is where the risk tends to be [which] is in these diagnoses and how the providers are selecting them,” she says.
Rock and Tuteur further discuss the complexity of Medicare’s payment to MA and the subsequent enforcement by Medicare. The compliance risk for the payer is complicated by each patient’s risk score, calculated based on the billing and demographic data submitted by the provider, and whether that score can be adjusted once a thorough medical record evaluation is completed. They also explain changes in the prior authorization process and the application of national coverage determinations and local coverage determinations in the threshold of care.
The Let’s Talk Compliance podcast is part of Foley & Lardner’s Health Care Law Today podcast series. Listeners can subscribe to both series on Apple Podcasts, Spotify, or their preferred podcast app.
All episodes of Let’s Talk Compliance also can be found on the PYA website.
If you would like assistance with developing or assessing a compliance program or conducting a preliminary Medicare Advantage Risk Adjustment Data Validation (RADV) audit or with any other matter related to compliance, regulatory requirements, strategy, or transactions, one of our executives would be happy to assist. You may email them below or call (800) 270-9629.