The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that nearly half of all directory locations reviewed were inaccurate. Breaking it down further, the inaccuracies ranged from 11% to 97.82%. We are living in an age of tech-savvy consumerism. If our GPS or Google results proved incorrect half of the time, we would not be satisfied. If results proved correct less than 3% of the time, we would be outraged.

“The report is a black eye for our industry,” said John Gorman, Gorman Health Group’s Executive Chairman in a recent Modern Healthcare article. “It’s easy to fix. We have to do better.”

Group practices continue to be a driver of non-compliance with plans listing information at the group level rather than the provider level. In addition to access to care concerns for beneficiaries, often the same database used for provider directories is also used when plans submit their Health Service Delivery (HSD) tables to CMS. By listing every group provider at all office locations, a plan is also inflating their network adequacy results. CMS has intimated any gaps between a plan’s online directory and their network adequacy need to be mitigated in short order and an internal process in place to ensure their continued alignment.

CMS noted the lack of internal auditing and testing remains a compliance gap. Plans have not built the necessary monitoring and oversight needed to be compliant. While there are pilot programs and a few vendors have emerged, technology at large to assist with the administrative burden is lacking. However, until technology or a central database is available, the onus is on the health plan and its providers to work together to ensure data accuracy. Health plans cannot assume a provider will be prompt and forthcoming with changes; a proactive, methodical outreach program coupled with diligent monitoring and oversight must be put into place.

Data inaccuracy tentacles are far reaching and jeopardize the success of numerous key health plan business functions and minimize the return on investment of supplemental investments such as Star Ratings or risk adjustment programs. CMS notes during their outreach in Year Two, information had been out of date for long periods. Providers were found to be retired or deceased for years. As one example of the financial impact, during recent network development projects to support service area expansions, the Provider Strategy team found the data inaccuracies in plan-provided contact information, currently in use for other lines of business, resulted in a significant number of additional hours expended to research and locate or determine the status of providers. The number of inconsistencies found were on par with the overall CMS average for Round Two; additionally, as CMS notes, we found a number of providers who had been retired, deceased, or relocated for a number of years, corroborating the need for plans to proactively reach out to providers on a routine basis

For Year Two, 23 plans were issued a notice of non-compliance, 19 plans were issued warning letters, and 12 were issued warning letters with a request for a business plan. This isn’t just a compliance concern — few things can tank your Star Rating and member experience scores faster than a shoddy provider directory or unexpected medical bills. Before your plan becomes a statistic, reach out to us at Gorman Health Group for assistance. We can provide a wide range of services – from performing a mock review to having a plan self-assessment available through our Online Monitoring Tool™ (OMT™).

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