CMS to Monitor Access to Care, Defines Provider Network Adequacy Pilot Program

During the Centers for Medicare & Medicaid Services (CMS) Audit & Enforcement Conference & Webinar held on June 16, 2015, CMS provided a glimpse as to how the Provider Network Adequacy (PNA) Pilot Program would begin to monitor beneficiary access to care.

The two-pronged approach will evaluate both provider network adequacy and the plan’s provider directory.  As we have seen over the past several months, from the Call Letter to the proposed Medicaid rule, there is a renewed focus on provider network access across all government-sponsored health plans.  The focus is on not only the beneficiary’s ability to access care in a timely manner but to ensure the member and referring providers have up-to-date demographic information on providers, including open/closed panel status.

Historically speaking, Medicare Advantage (MA) plans have submitted their provider and facility networks via Health Service Delivery (HSD) tables during their initial application or during a service area expansion (SAE). The HSD tables have been the source of truth for the MA plan to validate 90% of their enrollees had access to the full spectrum of providers and facilities within a given time and distance metric. Unless requested during the bid submission process, plans may not have validated their network against CMS standards from the original date of inception.  We have found from year to year, even with no changes to the provider network, it is possible for adequacy to change due to the beneficiary population files updated by CMS.  Additionally, we may have kept the same providers in the network but may not have captured changes, such as closing their panel to new patients, in our directories.  Fueled by increasing beneficiary complaints, plans will now be required to diligently monitor their providers and the provider office information.

As a result, CMS is supplementing the current guidance on provider directories and network access and availability reporting. CMS expects plans to establish and maintain a proactive, structured process to assess the availability of contracted providers on a monthly basis and monitor more closely member access to their provider network. CMS will monitor compliance via direct monitoring and the new PNA Pilot Program.

The new PNA Pilot Program will evaluate the two functional areas, network adequacy and provider directory, by requiring submission of HSD tables and by CMS calling a sub-set of providers from the HSD tables to monitor accuracy of information. The process, while still under development by CMS, is designed to promote continual self-evaluation by health plans. During the Audit & Enforcement Conference & Webcast, CMS outlined the process for the PNA requests.

• CMS will issue a Pre-Audit Issue Summary (PAIS)
  • Plans will have the ability to disclose network adequacy issues in two ways: sponsor-disclosed, meaning the issue was discovered by the plan and disclosed to CMS prior to the audit, or self-identified, meaning the issue was discovered by the plan after the start of the audit and self-reported to CMS.
  • In response to the network adequacy findings, plans will be asked to provide a Beneficiary Impact Analysis to disclose areas where beneficiaries will be affected by network issues. The impact analysis should be a three-month look-back at all beneficiaries who received care by the identified provider(s).
• Plan will also be asked to provide their provider directory to CMS.

A Sample PNA Audit Timeline:

• Within 5 business days of the engagement letter:
  • PAIS will be issued
  • Impact Analysis for PAIS
  • Provider Directory
  • Within 10 business days of the engagement letter:
    • HSD tables uploaded to Network Management Module (NMM)
    • NMM will provide plan with a report identifying all network deficiencies
    • Within 14 days of receipt of the deficiency notice:
      • Submit exception requests

The aggressive audit timeline will require plans to incorporate a robust network adequacy monitoring policy into its workflow processes.  When we look at the types of exception requests that will potentially be included in the final CMS policy, plans will not only need to be well-versed on their network but also the total number of providers/facilities available in their service area.  Plans must be able to identify patterns of care for their network and non-network providers, alternative providers that could provide the services, such as ENTs providing allergy clinics, and be able to pull the information together in a relatively short time.

The second portion of the audit process will be to ensure the provider directory is current for provider demographic information and open/closed panel status.  Per CMS, they will review a select representative sample of providers from the HSD tables and verify the directory information, by calling each provider office, to ensure the information available to the beneficiary is correct.  The Call Letter indicated plans should incorporate a robust policy to outreach to providers on a monthly basis to validate the provider’s network status and ensure any changes, both provider or plan initiated, are updated on a real-time basis.  CMS intends to further define the new policies and procedures governing the PNA Pilot Program and issue the guidance late summer/early fall via the Health Plan Management System (HPMS).

As CMS increases the scrutiny on provider network access and availability, we can only wait to see the impact it will have on a plan’s ability to move towards building a network based upon quality indicators and the value-based contracting and reimbursement models needed to shift providers into a population health and outcomes-oriented mindset.

Gorman Health Group can assist your organization navigate the network adequacy pilot and provide the infrastructure support solutions needed to build a smarter provider network. Contact me directly at emartin@ghgadvisors.com for more information.

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