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Provider Network Travails Become New CMS Compliance Focus

Provider Network Travails Become New CMS Compliance Focus

The Centers for Medicare and Medicaid Services (CMS) has found a new compliance focus that promises to challenge health plans into the future: provider network accuracy and adequacy.

While network adequacy is a complex and costly undertaking for plans applying to participate as a Medicare Advantage (MA) plan, scrutinizing how many providers really are or are not in established plans’ networks has been very much an after-thought for plans and CMS over the years. Faced with growing membership in private Medicare (about a third nationally and a majority in some large urban markets) as well as complaints about access to providers, CMS has begun tightening its regulatory oversight in the area.

On the application, plans must show how their network meets various thresholds with time and distance requirements to be allowed into the program. It is a cumbersome process, but one meant to ensure plans have a sufficient number of primary care, specialist, hospital, and ancillary providers to serve members in each of its covered counties. Post that fairly rigorous process, many plans lose focus and fail to retain sufficient providers in given specialties or counties. Additionally, plans fail to ensure providers accept their plan members or update the provider demographics and directories for correct locations.

CMS has begun to reform its approach to provider networks. While network adequacy was once just for initial application, today plans seeking to expand must re-validate their network adequacy in existing counties as well as proposed new ones. CMS has also begun studying how accurate provider directories published by plans really are. In a study released by CMS last week, the regulator announced that provider directories are riddled with inaccurate and incomplete information. CMS was shocked by the depth and breadth of the errors.

CMS looked at 54 Medicare Advantage plans’ directories and found that almost half of the 5,832 providers listed had incorrect information. Online directories were reviewed, which theoretically should be accurate given the new mandate this year for plans to contact providers quarterly for accurate information and update the directories so members have real-time information and are not relying on old, inaccurate printed versions. A major finding was the fact that doctors with multiple office locations were listed in the directories with locations that did not accept that plan’s Medicare members. Wrong phone numbers and addresses were also cited.

What will CMS likely do about all this?

  • First, it could issue civil monetary penalties or suspensions of enrollment on the plans already surveyed. CMS is very serious about its “no beneficiary harm” standard. It has issued sizeable fines in the past few years for inaccurate provider directory, Annual Notice of Change (ANOC), and Evidence of Coverage (EOC) documents.
  • Second, CMS says it is currently engaged in wide-scale monitoring efforts with respect to network accuracy and provider directories. The review noted above was done in the Fall of 2015. CMS will repeat the exercise this Fall and says it will review all plans by 2018.
  • Third, CMS also announced a provider network accuracy pilot audit. This audit will supplement the regular program audit but not be a part of it. The pilot will test the accuracy of the data in a plan’s provider directory as well as in their Health Service Delivery (HSD) tables. At least for now, adequacy will not be part of the test. When inaccuracies are identified, CMS will notify plans of these findings in their directories with instructions to correct the errors. Plans will have 30 days to correct. CMS will then revalidate both the provider directory and corresponding HSD tables. Again, plans that fail to correct and come into compliance may be subject to civil money penalties or enrollment sanctions.

Given the complaints from seniors and advocates, as well as the expected continued growth of MA membership, except this scrutiny to grow and intensify. For sure, CMS will add network adequacy to its current accuracy focus in the future.

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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