New Rules for Managed Care: Holding MCOs Accountable: DS25 Session

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.

• Display MAO Trend data 
  
• 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

Cost: $59 for AHCA/NCAL Members I $69 for Non-members

1 NAB credit available upon completion.  

Instructions to Register:

• For optimal performance, please use the latest version of Chrome, Firefox, Edge, or Safari 14+. 
• Members will need to log in using their existing email and password first. 
• Once you are logged in to the website, you will be able to register by clicking the green register button at the top right of the page. 
• If you have forgotten your password, click here. 
• If you are new to the site, you can create an account here. Answer all fields on the 'Create an Account' page, especially when locating your company name. You can search by name or zip code. After creating an account, you will be able to register. 
• If you are unsure if you are a member of AHCA, you can email update@ahca.org to confirm your membership status. 

Instructions to Begin, after registering: 

• To begin the training, click on the Contents tab.
• Participants can move throughout the lessons in the course by clicking on the header of each module to expand or minimize their view. 

Completion Deadline 

Individuals have until Oct. 31, 2026 to complete. After October 31st, 2026, this session will no longer be available to access or earn additional CEs.

Email educate@ahca.org if you need technical assistance.

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