CMS Spotlight on Provider Directories & Network Adequacy

As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage (MA) plans’ provider network, with emphasis on both online provider directories and network adequacy.

CMS plans to monitor compliance of plans’ adherence through direct monitoring with additional contract funds and through the development of a new network adequacy audit protocol to be tested in 2015 that will determine whether the provider network meets published CMS adequacy standards. The compliance and enforcement of the new protocols will include civil money penalties (CMPs) and enrollment closures.

Recent beneficiary complaints have brought into focus the accuracy, or lack thereof, with Medicare Advantage Organizations’ (MAOs’) online provider directories.  Beneficiaries, and sometimes referring providers, have shown frustration in attempting to make an appointment, only to find the provider is no longer accepting new patients, has moved, or is no longer participating with the plan.  CMS has supplemented their current guidance on provider directories and expects plans to:

• Establish and maintain a proactive and structured process by which to verify the availability of its contracted providers. This process will include outreach, on a monthly basis, to verify there has been no change in a provider’s address, phone number, and office hours, and determine if the provider’s panel is open or closed to new patients,
• Establish a policy to review and address beneficiary complaints when they are denied access to a provider(s), and
• Include a provision for real-time updates to the online directory.

Additionally, the Call Letter announced a new network adequacy protocol to be tested in 2015.  During his presentation at the CMS Medicare Advantage Prescription Drug Plan (MA-PD) Spring Conference & Webcast, Greg Buglio provided insight concerning the upcoming audit protocol.

Mr. Buglio shared that the Network Management Module (NMM) is a standalone module, a version of which currently resides within the Health Plan Management System (HPMS), which may be utilized by MA plans to submit Health Services Delivery (HSD) provider and facility tables for evaluation against CMS HSD criteria.

CMS notes a robust version of the NMM will be released at the end of July 2015.  According to CMS, the new version will be highly flexible and support a variety of reasons for HSD submission.  The updated NMM will support CMS-initiated requests for submission of HSD tables and exception requests for various processes. Once released in late summer/early fall, the NMM will contain user guides, help screens, and templates for HSD submission.

The NMM will also permit plan-initiated submissions.  It was noted plan-initiated submissions will not be viewable or evaluated by CMS.  The goal is that plans will be encouraged to continuously self-evaluate their own network adequacy against CMS’ criteria. Presently, CMS only reviews network adequacy with initial and service area expansion applications. We anticipate the self-evaluation will work similar to the network pre-checks available during the application process. It was noted the templates within the NMM would not be the same template used during the application process. The two templates will not be interchangeable.

We anticipate further guidance surrounding the network adequacy protocol to be presented during CMS’ upcoming MA-PD Audit & Enforcement Conference & Webcast  taking place on June 16.  Prioritize this event, and attend either in person or via webinar.

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