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This year’s Federal SWAT event will occur over two days, beginning with an ERISA pre-conference workshop on November 7, followed by a full-day Medicare Advantage Academy program on November 8. All sessions will be led by experts from King & Spalding, a renowned national law firm. Register today!

ERISA Pre-conference Workshop — Wednesday, November 7

4 - 5:30 p.m.

This workshop will focus on claims against self-funded plans and ERISA preemption fundamentals. Participates will discuss strategies related to:

  • litigating claims disputes against self-funded plans—contracted vs. assignment of benefits;
  • ERISA remedies;
  • conditions of admissions and patient collections; and
  • case for reforms in ERISA law.

Medicare Advantage Academy — Thursday, November 8

8:30 - 8:35 a.m.

Welcome and Introduction

8:35 - 9:30 a.m.

Medicare Advantage Fundamentals

This session will cover:

  • an overview of Part C and its contrasts with regular Medicare;
  • an overview of regulations;
  • an overview of the Medicare Advantage Manual and other guidance;
  • Medicare Advantage Plan contracts with CMS;
  • the Medicare Advantage Plan application and rate setting process; and
  • rules for in-network versus out-of-network.

9:30 - 11:15 a.m.

Provider Contracting

This session will cover:

  • typical commercial contracting strategies and approaches;
  • typical business issues raised by payer templates; and
  • specific Medicare Advantage contracting issues.

A group breakout exercise will take place after the formal presentation. Small groups will review sample contracts, identify holes and traps, and propose solutions.

11:15 a.m. - Noon

Payment Issues

This session will cover:

  • payment requirements;
  • emergency care, urgently needed care, and post-stabilization care;
  • “essential hospitals”;
  • PFFS and “deemed” providers;
  • secondary payer issues; and
  • sequestration.

Noon - 12:45 p.m.

Lunch Break and Networking

12:45 - 2 p.m.

Denials and Appeals

This session will cover:

  • an overview of rules and regulations for in-network versus out-of-network;
  • typical contracted plan appeals procedures and required actions;
  • typical non-contracted plan appeals procedures and required actions;
  • managing appeals of large numbers of individual claims;
  • contract dispute resolution; and
  • non-contract dispute resolution.

An appeals writing workshop will then take place, using information learned in this session. Participants will work through sample administrative denials, DRG downgrades, and clinical denials, then prepare appeals and discuss them as a group.

2 - 3:30 p.m.

Strategies for Challenging Unsatisfactory Medicare Advantage Plan Behavior

This exercise will cover practices encountered by plans and strategies to overcome them, including:

  • unsatisfactory behavior:
    • violations of the provider agreement;
    • failure to provide the full Medicare benefit to the patient (and provider as assignee);
    • material adverse unilateral amendments;
    • abusive records requests and audits; and
    • attempts to operate with inadequate network adequacy; abuse of non-contracted providers.
  • practices falsely claimed to be “required by CMS”;
  • CMS’s role in enforcing Medicaid Advantage requirements and handling provider grievances; and
  • tactics and what to expect: terminate, litigate, or arbitrate?

Following the formal presentation, sample payer practices will be provided to small groups for resolution in the day’s final group breakout exercise.

3:30 - 4:30 p.m.

Town Hall: Open Issues

4:30 p.m.