Maureen McCarthy, RN, BS, RAC-MT, QCP-MT, DNS-MT, RAC-MTA: No financial relationships to disclose
Significant reforms to managed care oversight were introduced in the Medicare Advantage Final Rule for Contract Year (CY) 2024, with full implementation beginning January 1, 2024. Now, nearly two years into enforcement, providers and managed care organizations (MCOs) are adjusting to heightened federal expectations. Under these rules, MCOs must follow traditional Medicare coverage criteria, limit prior authorization requirements, and respect the clinical judgment of treating providers.
This session—led by long-term care reimbursement expert Maureen McCarthy—will examine how these changes have reshaped the provider-MCO dynamic. Attendees will explore compliance gaps, review best practices in contesting denials, and consider strategies to safeguard access to care for Medicare Advantage beneficiaries in skilled nursing settings. Drawing on real-world experiences, Maureen will share insights on operationalizing these rules and holding MCOs accountable to ensure care continuity and regulatory compliance.
Learning Objectives:
Review the CY24 and CY25 Final Rule changes for MAOs that are available to assist providers with claims denials
Discuss the changes to Medicare Advantage plan coverage criteria impacting early termination denials of care
Identify CY26 proposed changes for MAO claims appeals process
Explain how an appeals tracking system can assist in managing MAO claims appeals
