Update on CMS Spotlight on Provider Directories and 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 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 2016 which will determine whether the provider network meets published CMS adequacy standards. The compliance and enforcement of the new protocols will include civil money penalties and enrollment closures.

Recent beneficiary complaints have brought into focus the accuracy, or lack thereof, with Medicare Advantage Organizations’ 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 with additional updates on August 13 and November 13, 2015, and expects plans to:

Establish and maintain a proactive and structured process in which to verify the availability of its contracted providers.

In their August 13, 2015, update, CMS clarified the requirement does not apply to entities such as hospitals, and plans should use a method likely to achieve the highest response rate. This process was further updated on November 13, 2015, and effective immediately will now include outreach on a quarterly basis to verify:

  • There has been no change in a provider’s address or phone number and determine if the provider’s panel is open or closed to new patients. CMS provided additional guidance that plans should include a notation in the online directory identifying providers who are accepting new patients or a notation identifying providers who are not accepting 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. In a memo released on November 13, 2015, CMS further defined “real-time” to mean within 30 days to be consistent with other Marketplace regulations.

It is important to note CMS’ core focus remains ensuring provider directories are accurate for Medicare beneficiaries and their caregivers who rely on them to make informed decisions regarding their healthcare choices.

As you prepare to meet the new challenges for maintaining an up-to-date provider directory, changes to network submissions for service area expansions, or preparations in anticipation of the network adequacy (pilot) audit, please feel free to reach out and let us know how Gorman Health Group can assist you!

Contact me directly at emartin@ghgadvisors.com to learn more.



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