This advanced session provides healthcare administrators, managed care providers, and compliance officers with a deep-dive into the latest Medicare regulations under 42 CFR Part 417. The updated rule includes significant requirements that impact organizations contracting with CMS to serve Medicare beneficiaries. From financial risk requirements to detailed administrative controls, attendees will explore the essential compliance frameworks needed to ensure contractual success and audit-readiness.
Areas Covered:-
- HMO and CMP contract qualifications (operational, preoperational, and transitional statuses)
- Administrative and management standards
- Financial solvency, net operating surplus requirements, and insolvency protection plans
- CMS application and determination procedures
- Risk assumption and allowable insurance arrangements
- Required reporting and combined financial statements
- Compliance with Federal employee health benefit integration rules
- Audit processes, enforcement actions, and revocation procedures
- Waivers, exceptions, and civil action provisions
Learning Objectives:-
- Understand Medicare contract eligibility requirements for HMOs and CMPs
- Master the operational, financial, and management standards under 42 CFR Part 417
- Identify CMS application steps and review processes
- Learn how to prepare organizational financial disclosures and required reports
- Develop policies for member protection and insolvency risk mitigation
- Prepare for CMS investigations, audits, and enforcement procedures
Who Should Attend?
- Healthcare executives
- Managed care directors
- Compliance officers
- Legal counsel for healthcare organizations
- Billing and credentialing managers
- Risk management officers
- Financial officers
- Administrators seeking Medicare contracting guidance
- Managed Care Organizations (MCOs)
- Medicare Advantage Plans
- Group and Solo Practices with Medicare risk contracts
- Billing and credentialing companies
- Compliance and legal teams
- Healthcare consulting firms
- Provider networks
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Keisha Wilson, CCS, CPC, CPCO, CPMA, CRC, CPB, AAPC Approved Instructor, the founder/ CEO of KW Advanced Consulting, is a seasoned professional with over 20+ years of experience in the healthcare field. Her career in large teaching hospitals and acute ambulatory care systems includes roles such as an outpatient coding specialist, clinical documentation improvement (CDI) specialist, compliance operations coding and billing manager, interim compliance director, and consultant to various coding companies. Her extensive experience is a testament to her leadership and deep understanding of the industry.
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