The Importance of Accurate Provider Data and Network Adequacy

For almost two years, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and, potentially, sanction. As we saw with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. CMS released its first “Online Provider Directory Review Report” in January 2017 and followed up on January 17, 2017, with a CMS Memo on Provider Directory Policy Updates.

In addition to the regulatory compliance and existing provider directory requirements, CMS noted two additional guidance steps:

  1. For group practices, directories must only list individual provider at locations where they routinely see patients, as opposed to every location of the group practice.
  2. Organizations must make a reasonable attempt to ensure provider practice names are up to date and reflect the name stated when an enrollee calls to make an appointment.

CMS also noted plans should institute other steps to ensure the information included in their directories is accurate and useful to their members. One item suggested was that plans have a hotline for members to use when they encounter a directory issue, such as a provider no longer accepting new members. The plan should then use this information to investigate and correct the issue for the member. Moreover, CMS readdressed the issue that any issues found during a directory self-audit, CMS audit, or member or provider calls should also be updated and ensure accuracy in the Health Service Delivery (HSD) tables used to submit the provider network to CMS.

Overall, plan provider networks have never had the scrutiny of CMS or other spotlight and as such have tended to take a back seat to issues unless a particular grievance was filed. At Gorman Health Group, we keep a pulse on the various health plan areas on which our organization consults as we regularly have cross-functional projects. I asked a Compliance colleague how her Compliance meetings went at a plan, and she responded that every meeting expounded upon their fear of not meeting the network and directory regulatory guidance. I discussed the directory issues with an operational colleague, and her comment from a recent project on member calls was that “approximately 40% of member calls were due to directory issues.”

For this blog, I had a chance to ask another colleague, one of our subject matter experts on Stars, to give her perspective:

Accurate provider data is a mission-critical foundation for a strong Star Rating.  If provider data is inaccurate, members will likely struggle to access providers or may actually show up at the wrong location for an appointment.  These issues influence all Star Ratings measures; they directly impact clinical quality measures and indirectly impact member survey and administrative measures.  In addition, inaccurate provider data jeopardizes the success of numerous key health plan business functions and minimizes the return on investment of supplemental investments in Star Ratings, Risk Adjustment, and Quality Improvement (QI).

The nature and extent of inaccuracies within a health plan’s provider directory has, to date, often been a well-kept secret within health plans.  Though data hygiene of names, addresses, and phone numbers is undoubtedly a very basic administrative function, competing priorities inside of a plan often redirect administrative staff away from these time-consuming, mundane activities until a crisis occurs (such as a CMS audit of the data or “ride-along” conducted for Star Ratings, Risk Adjustment, or QI purposes).

Perhaps even more troubling is when a provider listed in the directory is not accepting new patients.  Although CMS recognizes this can be a “fluid item” in the directory, Medicare Advantage enrollees often select a plan specifically based on a provider’s participation in that plan’s network.  When these situations arise, the health plan’s credibility and brand loyalty are placed at risk, and the member’s healthcare experience and Star Ratings status are placed in jeopardy.

Part of the anxiety is easy to diagnose: it is a new requirement, and we need to find the best approach. However, if you dig deeper, you will find directory data is the tip of the iceberg. Provider network operations in some plans can have functionalities that reside in several difference departments such as Provider Relations reporting to Operations, Credentialing reporting to Medical Management, and Contracting reporting to Finance. Like many plans, the functions were done in silos.

In retrospect, the issues identified are not new. They do, however, expose a systemic issue with provider network operations and the downstream impact they will have.

Please join us at the Gorman Health Group 2017 Forum as we further discuss the Provider Directory Accuracy and Network Adequacy regulatory requirements as well as the downstream impact they have on our internal operations and our external vendor operations. In the meantime, please contact us directly if you have questions or would like to schedule a time to meet with one of our industry experts to discuss how Gorman Health Group Forum can support your efforts to avoid risk and improve results.


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