Medicare Advantage Plan Audits and Tips to Win

  • Course level: All Levels
  • Duration 1h
  • Last Update November 11, 2021


Medicare advantage organizations are required to comply with all Medicare part C & D program requirements. CMS is conducting program audits of MA plan providers to evaluate providers’ compliance with the requirements. The audits will focus on high-risk areas that have the greatest potential for beneficiary harm. As such CMS has developed the following audit protocol for use by providers to prepare for their audit:

  •  Compliance program effectiveness
  • Part D formulary and benefit administration
  • Part D coverage determination, appeals, and grievances
  • Part C organization determinations, appeals, and grievances
  • Special Needs Plans Care Coordination (SNPCC).

Medicare Advantage (“MA”) programs are more common these days, with a significant portion of Medicare beneficiaries currently enrolled in different programs. MA programs are issued by Medicare Advantage Organizations (MAOs)—usually, insurance companies; acting as government agents.
MA plans are popular with the aged population because MA plans offer additional health care coverage for little to no cost, unlike the traditional Medicare program. At the same time, MAOs pre-capitated, risk-adjusted payments from Medicare, which means that an MAO will get more reimbursements when it renders services to more severely ill patients.
A high-risk-based model incentive the MAO to diagnose consumers with high-risk diseases in order to gain more payments. Some MAOs use additional diagnoses to attain high-risk scores, while not necessarily reflecting these diagnoses in any documentation.
Healthcare providers tend to have issues with MA programs, hence issues with the audits. Payment and claim adjudication can occur through contracts that may differ, which definitely vary from the rules and regulations found in traditional Medicare. Rules and regulations, when it comes to Medicare, trumps a contract. You cannot contract in violation of the law; the contract will be stricken. So providers need to know the rules and regulations more than their contracts.
If a non-contracted healthcare provider is offering services, then the MAO makes a payment under traditional Medicare rules and regulations. This provides an opportunity to question how an MAO can adjudicate a claim under standard Medicare rules, while the MAO’s adjudication system has been developed to address claims. We will discuss audits of MA providers in-depth, including when traditional Medicare rules apply and when MA rules apply.
To ensure that the system is being run fairly, the Centers for Medicare and Medicaid Services (CMS) instituted Medicare Advantage audits.
This webinar will teach you how to defend yourself against a MA audit. We will discuss creating a data-driven operation and create a comprehensive outline for “what to do if you are audited.” You will learn to be proactive regarding your defenses against a MA audit.
If you accept Medicare Advantage, you will be audited and you should listen to this webinar.

Areas Covered in the Session:

  • Medicare Advantage
  • Medicare Advantage law, rules, regulations, and policies
  • Medicare Provider Manual
  • Applicable case law
  • Process of Medicare Advantage audits
  • Legal defenses to Medicare Advantage audits
  • Common mistake auditors make
  • How to discredit auditors
  • Defenses against extrapolation
  • MA audit appeal process
  • Tips for successfully getting through a Medicare Advantage audit

What Will I Learn?

  • Understanding Medicare Advantage
  • Differences between Medicare Advantage and traditional Medicaid audits
  • How you are targeted
  • How you can avoid being targets
  • The procedural process of a Medicare Advantage audit
  • Who are the Medicare Advantage auditors?
  • How to discredit Medicare Advantage auditors
  • Is extrapolation allowed in Medicare Advantage audits?
  • What are the limits to Medicare Advantage audits?
  • How to defend Medicare Advantage audits
  • The appeal process
  • Success rate number

Topics for this course

1 Lessons1h

You can access all the webinar materials after successful payment

Webinar Link + Transcript

About the instructor

For more than 20 years, Knicole has maintained a healthcare litigation practice, concentrating on Medicare and Medicaid litigation, healthcare regulatory compliance, administrative law, and regulatory law. She understands the intricate Medicare and Medicaid payment system, the unique business of healthcare providers, the overlay of federal and state Medicare and Medicaid rules and regulations, and the actions of state agencies that affect the way healthcare entities operate. Knicole has tried over 2,000 administrative cases in over 30 states and has appeared before multiple states’ medical boards. Knicole has successfully obtained federal injunctions in numerous states, which allowed healthcare providers to remain in business despite the state or federal laws' allegations of healthcare fraud, abhorrent billings, and data mining. Across the country, Knicole frequently lectures on healthcare law, the impact of the Affordable Care Act, and regulatory compliance for providers, including physicians, home health and hospice, dentists, chiropractors, hospitals, and durable medical equipment providers. She is a weekly panelist on RACMonitor, as a national expert on Medicare and Medicaid audits. Prior to joining Practice, Knicole was Co-Chair/Managing Partner of the Healthcare Practice with Gordon & Rees and served as North Carolina Assistant Attorney General in the Health and Public Assistance Section where she gained a thorough understanding of the Medicaid system that informs her practice today.
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Material Includes

  • PDF
  • Full Webinar Video with unlimited access
  • Transcript


  • System Requirement Operating System: Windows any version preferably above Windows Vista & Mac any version above OS X 10.6
  • Internet Speed: Preferably above 1 MBPS
  • Headset: Any decent headset and microphone which can be used to talk and hear clearly

Target Audience

  • Hospital executives like CEOs, COOs, CFOs, CNOs, and CMOs
  • Healthcare providers who accept Medicare Advantage
  • Healthcare providers who anticipate accepting Medicare Advantage
  • Healthcare attorneys
  • Healthcare billers
  • Doctors
  • Nurses
  • Compliance Officers
  • Administrators
  • Department Heads
  • In-house legal counsel
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