Provider Networks Adequacy: Compliance Tips for Medicare Plans

By Derek Frye
Thu, Mar, 09, 2017

 The Centers for Medicare and Medicaid (CMS) is stepping up the scrutiny of and corrective action plans for Medicare Advantage Organizations (Sponsors) that fail to keep their provider networks directories’ information accurate and up-to-date.

A report released by the agency in January 2017 available here– based on a review of 54 Sponsors conducted in 2016 – found that on average, 45% of provider entries listed in on-line provider directories are inaccurate. Most of the inaccuracies involved incorrect phone numbers, providers not being at the locations listed, and providers being listed as accepting new patients when, in fact, they weren’t.

Additionally, CMS found that within each individual Sponsor provider network’s directory examined, the percent of inaccuracies ranged from as low as under 2% to as high as 87% -- a huge variation. A majority of Sponsors reviewed by the agency fell somewhere between 30% and 60% inaccuracy rates. As a result of the reviews, CMS issued plans 31 notices of non-compliance, 18 warning letters, and 3 warning letters with a request for business plan.

Given these findings, CMS now intends to review all Sponsors over the next three years for provider directory listing accuracy. The agency plans to review one-third of all Sponsors in 2017 with the remaining plans reviewed in 2018 or 2019.

Why is CMS so concerned about these listings? In CMS’ view, because Medicare beneficiaries rely on these listing to locate in-network providers, inaccuracies on such a scale pose significant access-to-care barriers.

So what should Medicare Advantage plans do in light of the agency’s new emphasis on provider directory accuracy?

First, health plans need to take stock of where they are today. How accurate is your current directory? What process is used for updating it? Who owns it internally? Do you work with a vendor, and if so, what is their process? Identify where there are gaps or breakdowns in the current process so you can address them.

Second, health plans should be able to show CMS that they either have or are in the process of conducting good due diligence internally. Don’t just rely on some other department, such as credentialing, or your outside vendor, to handle the due diligence. What steps is the organization as a whole taking to identify and then remedy problems?

Third, develop an execution plan. CMS wants health plans to eventually achieve a 95% accuracy rate. That’s setting the bar high. So you will need to develop a plan and tackle it in stages to get to that level. Here are some specific things health plans may want to consider as part of that plan:

  • Focus first on improving on areas that CMS weights most heavily when scoring plans in this area. For example, plans are found to be more deficient if they publish incorrect provider phone numbers, compared with if they publish incorrect addresses or an incorrect specialty associated with the provider.
  • Plan resources accordingly. Getting the directory accurate may involve having a temporary army of people do phone surveys to verify provider listing accuracy. You may want to hire this part of the project out and then develop an internal plan for getting the updated information into your systems.
  • Consider how you want to work with your providers to ensure accurate listings. You can consider setting up on-line automated surveys. Or you can build something into your provider contracts requiring them to update their information on a regular basis.
  • CMS, as a best practice, is strongly encouraging MCO’s to provide a hotline number putting members in direct contact with the plan if they uncover an error, including if the provider is not accepting new patients. The MCO can use this information to quickly update its directory information.
  • If you need additional support, consider hiring a consultant familiar with CMS compliance and weighting factors to help you design a plan. They can help you prioritize which areas to focus on and recommend approaches that have already worked well for other plans.

Keeping your online provider network directory accurate on a regular basis can feel like a cumbersome task. But it’s important to focus on this, now that CMS is giving this area greater scrutiny. Using some of the steps outlined here should help make the process smoother.