Season 8 - Episode 9 - Monday Auditing, Coding and Compliance Roundtable

The Compliance Guy

Summary

The conversation delves into the complexities of Medicare Advantage plans, highlighting concerns about their effectiveness and the implications of recent changes in coding. The panel discusses the challenges faced by patients under these plans, the deceptive marketing tactics used, and the potential shift towards remote patient monitoring as a solution for chronic condition management. The discussion emphasizes the importance of understanding the differences between Medicare Advantage and traditional Medicare, particularly in terms of patient access to care and the quality of services provided. In this conversation, the panel discusses the complexities of medical necessity in remote patient monitoring (RPM) and the challenges faced by healthcare providers in navigating federal and state regulations. They emphasize the importance of understanding medical necessity, adhering to payer policies, and the implications of compliance in healthcare. The discussion highlights the disconnect between providers and regulatory guidelines, the need for clear communication, and the consequences of non-compliance.

Takeaways

• Medicare Advantage has a checkered history with inflated coding data.
• CVS's financial issues are linked to Aetna's Medicare Advantage business.
• Medicare Advantage plans are facing scrutiny for pre-authorization practices.
• The shift to Medicare Advantage may not benefit all retirees.
• Medicare Part B offers more direct access to care than Medicare Advantage.
• Deceptive marketing tactics are prevalent in Medicare Advantage advertising.
• Patients need to be educated about their Medicare options.
• Changes in coding have significant implications for Medicare Advantage payments.
• Concierge medicine is emerging as a trend within Medicare Advantage.
• Remote Patient Monitoring (RPM) is gaining traction for chronic condition management. Practices need to fully grasp medical necessity for RPM.
• There are still deficiencies in guidance from CMS and HHS.
• Medical necessity is often lost in ambiguous regulations.
• Providers must understand the implications of their actions.
• State laws can trump federal guidelines in healthcare.
• Telehealth consent requirements vary by state.
• Healthcare compliance is complex and multifaceted.
• Providers should seek clarity on regulations from their administrators.
• Ignorance of regulations can lead to serious consequences.
• It's essential to follow the specific guidelines of your MAC.