Legal Limits: What Medicare Advantage must cover (and how it often doesn’t) with Richelle Marting

Listen to the episode here.

Medicare Advantage. It’s everywhere you turn. From upcoding to denials, the huge and growing program—which now covers more lives than traditional Medicare, but is increasingly the target of local and federal scrutiny and a stream of endless OIG audit reports—seems to be in the news daily.

In a sea of online anger and noise, there’s a few voices of reason, reminding us about the regulations and guidelines and how MA should be conducting itself—at least in theory.

One such person is Richelle Marting. Richelle is an RHIA and a JD and owner of a host of coding credentials besides. As a Healthcare Reimbursement Attorney and Founder of Marting Law, LLC, she brings a unique legal viewpoint to medical coding, coverage, and payment. She knows what regulations bind Medicare Advantage plans—and how these are often skirted.

On this show we cover:

• Richelle’s start to 2025, personally and professionally
• What MA plans must cover and pay for, by law
• Prior authorization
• Under which circumstances MA plans can use internal coverage criteria
• How MA plans game the system: three sneaky tactics you won’t want to miss
• The latest on automated denials/use of AI
• Richelle’s answer to the question: Medicare Advantage: Yay or Nay?
• An interesting new year’s resolution and latest addition to the OTR Spotify playlist

Richelle’s desktop MA policy links:

Governing rules for Medicare Advantage: Code of Federal Regulations 42 Part 422: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C

Final rule for MA plans (April 2023), 4201-F: https://www.federalregister.gov/documents/2023/04/12/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program

Medicare Internet-Only Manuals: https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms

Medicare Advantage 2026 proposed rule: https://www.federalregister.gov/documents/2024/12/10/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare