Fighting Back To Win against Medicare Advantage carriers

Presenter: Don Self, CPC, CMCS, CASA

Date: Thursday, November 05, 2026

Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT

Duration: 90 minutes

Course Description

Medicare Advantage enrollment continues to grow across the United States, bringing increased scrutiny to coverage determinations, prior authorization requirements, reimbursement policies, and appeals processes. While Medicare Advantage plans administer Medicare benefits through private insurers, they remain subject to federal Medicare regulations and coverage standards. Understanding these requirements is essential for healthcare providers, coding professionals, revenue cycle leaders, and practice administrators seeking to protect both patient access to care and appropriate reimbursement.

Join nationally recognized healthcare reimbursement consultant Don Self, CPC, CMCS, CASA, for this practical and highly informative 90-minute webinar designed to help healthcare organizations navigate the increasingly complex Medicare Advantage landscape. Drawing on decades of experience in Medicare reimbursement, compliance, coding, and appeals, Don will provide attendees with actionable strategies for identifying improper denials, challenging adverse coverage decisions, and leveraging federal regulations when responding to payer disputes.

Participants will gain a clear understanding of how Medicare Advantage plans must apply Medicare coverage rules, including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and other Medicare benefit requirements. The session will explore the relationship between prior authorization and medical necessity, common denial scenarios, payment obligations for providers, recoupment and offset practices, and the protections available through organization determinations and formal appeal rights.

Beyond traditional appeals, the webinar will examine powerful oversight and escalation pathways available to providers and beneficiaries, including CMS complaint processes, the Complaint Tracking Module (CTM), BFCC-QIO quality-of-care complaints, and Medicare Advantage Star Ratings. Attendees will also learn how to strengthen carrier correspondence, document disputes effectively, and use regulatory authority to support payment and coverage challenges.

Through real-world examples, practical guidance, and proven strategies, this session will equip healthcare professionals with the knowledge and tools needed to confidently address Medicare Advantage denials, safeguard revenue, support compliance efforts, and advocate effectively for both their organizations and their patients.

Learning Outcomes

• Explain how Medicare Advantage differs from Traditional Medicare while remaining subject to federal Medicare requirements.
• Identify Medicare Advantage coverage obligations under 42 C.F.R. § 422.101 and explain the role of NCDs, LCDs, and general Medicare coverage rules.
• Evaluate prior-authorization denials and determine when the underlying service may still meet Medicare coverage requirements.
• Recognize key payment protections for non-contracting providers and distinguish network status from Medicare benefit entitlement.
• Apply Medicare Advantage clean-claim payment rules, including the 30-day payment requirement and applicable interest provisions.
• Identify due-process concerns involving recoupments, offsets, organization determinations, and appeal rights.
• Challenge extrapolated overpayment demands by requesting the legal authority, sampling methodology, and statistical support.
• Use CMS complaint and oversight pathways, including CTM and BFCC-QIO processes, when plan actions interfere with patient care or Medicare requirements.
• Explain why Medicare Advantage Star Ratings matter to plans and how complaint activity can become a meaningful compliance issue.
• Draft stronger carrier correspondence using specific federal authorities, supporting documentation, and clear escalation steps rather than generic appeal language.

Areas Covered in the Session

• Medicare Advantage Market Overview
  • Market size and growth
  • Financial incentives and plan structures
• How Medicare Advantage Plans Are Paid
  • Risk adjustment
  • Diagnosis coding and HCC scoring
  • Payment incentives
• Medicare Advantage Regulatory Framework
  
• Medicare Coverage Requirements
  • 42 C.F.R. § 422.101
  • Part A and Part B coverage
  • NCDs and LCDs
  • General Medicare coverage conditions
• Prior Authorization vs. Medicare Coverage
  • Coverage requirements vs. utilization controls
  • Identifying improper denial rationales
  • Framing effective denial challenges
• Common Payer Statements and Provider Responses
  
• Out-of-Network & Non-Contract Provider Payments
  • Payment obligations
  • Network status vs. Medicare benefit entitlement
  • Non-contracting provider protections
• Clean-Claim Payment Requirements
  • 30-day payment rule
  • Late-payment interest
  • Qualifying claims
• Recoupments and Payment Offsets
  • Due-process considerations
  • Notice requirements
  • Preserving appeal rights
  • Organization determinations
• Medicare Advantage Appeals
  • Appeal timelines
  • Supporting documentation
  • Escalation strategies
• Extrapolated Overpayment Demands
  • Universe and sampling methodology
  • Random sampling and confidence intervals
  • Statistical support
  • Legal authority for extrapolation
• CMS Complaint Tracking Module (CTM)
  • When CTM may be appropriate
  • Supporting beneficiary complaints
• BFCC-QIO Quality-of-Care Complaints
  • Quality-of-care concerns
  • Delayed or interrupted medically appropriate care
  • Provider support for beneficiary complaints
  • Escalation considerations
• Medicare Advantage Star Ratings
  • Member experience
  • Complaints and appeals
  • Compliance implications
  • Plan performance considerations
• CMS Oversight & Practical Dispute Strategies
  • Effective carrier correspondence
  • Supporting documentation
  • Federal regulatory citations
  • Sample letters and escalation approaches
• Interactive Q&A Session with Don Self

Recommended Participants

• Physicians (MD, DO)
• Nurse Practitioners (NP)
• Physician Assistants (PA-C)
• Practice Administrators
• Medical Practice Managers
• Revenue Cycle Managers
• Billing Managers
• Medical Billers
• Certified Professional Coders (CPC)
• Certified Coding Specialists (CCS)
• Compliance Officers
• Appeals and Denials Specialists
• Medicare Advantage Specialists
• Revenue Cycle Directors
• Coding and Billing Managers
• Healthcare Consultants
• Credentialing and Contracting Staff
• Medical Auditors
• Healthcare Attorneys
• Staff responsible for Medicare Advantage claims, denials, appeals, and payment follow-up

About the Presenter

Don Self, CPC, CMCS, CASA, is a nationally known healthcare reimbursement consultant, educator, and author with more than four decades of experience working with physicians, medical practices, managers, billers, and coders. He is President of Don Self & Associates, Inc. and Telecare-USA, Inc., and is known for teaching medical practices how to understand the rules behind reimbursement rather than simply accepting payer denials and payment reductions.

Don’s work focuses heavily on Medicare, Medicare Advantage, coding, reimbursement, appeals, denials, recoupments, federal regulations, and practical strategies for protecting both patient access and practice revenue. He teaches live seminars and webinars nationwide and writes in the same plainspoken style he uses in the classroom: show the rule, explain what it means in real life, and then show the practice what to do next.

His programs are designed for people who want practical, usable answers they can take back to the office and put to work immediately.