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Provider Network Review: The Next Great Compliance Bogey

Another compliance headache hits plans!

The Centers for Medicare and Medicaid Services (CMS) completed its second round of Medicare Advantage (MA) online provider directory reviews between September 2016 and August 2017. The review looked at the accuracy of 108 providers and their locations selected in 64 MA plans’ directories (about 1/3 of MA plans, 6,841 providers, and 14,869 locations).

CMS’ findings:

  • Overall, 52.20% of the provider directory locations listed had at least one inaccuracy.
  • Inaccuracies included:
    • The provider was not at the location listed.
    • The phone number was incorrect.
    • The provider was not accepting new patients when the directory indicated they were.

CMS says the percent of locations with inaccuracies for each plan ranged from 11.20% to 97.82%, with the average being 48.39%. The majority of plans surveyed had between 30% and 60% inaccurate locations.

The findings are of grave concern to CMS and represent the next great compliance focus for the regulator. Network adequacy is a complex and costly undertaking for plans applying to participate. However, scrutinizing how many providers that really are or are not in an established plan’s networks has historically been an after-thought for plans and CMS. Faced with growing membership in private Medicare as well as complaints about access to providers, CMS now will tighten its regulatory oversight in the area by doing a triennial review of plan networks. Fines and potentially suspensions surely will result.

KEY TAKEAWAYS:

  • Provider network accuracy is next big compliance headache for plans
  • Review in this area will become as thorough as a standard audit

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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