The Future of Medicare Advantage Provider Directory Requirements

By Shelley Segal, Principal at Medicare Compliance Solutions

Through their first round of Medicare Advantage (MA) online directory audits, CMS has made it clear to health plans they will continue to aggressively identify and pursue instances of non-compliance by using a host of oversight methods. The results from the first round identified significant errors and many of the findings suggest that, at a minimum, there will be increased frustration from members and may significantly prevent access to care.  The intent of the new regulations has been to afford beneficiaries and their care givers the protection and tools needed to make the most informed decisions about their healthcare coverage. My favorite analogy used thus far has been “What if your GPS was correct less than 50% of the time?”  We know that as consumers we would not be happy with any product with an error rate that high.

CMS has developed an initial process for monitoring provider directory accuracy, and the data collected through these monitoring activities will drive future reviews, monitoring, and audit-based activities of network adequacy.  In the follow-up memorandum to the initial directory audit findings, released on January 17, 2017, CMS brought directory accuracy full circle with network adequacy by noting that plans should assess their networks to ensure that changes made to the directory are accurately updated and in accordance with the plans Health Service Delivery (HSD) tables. For example, if the plan finds there are a large number of primary care providers who are no longer accepting new patients, there should be a process in place to assess the recruitment needs for the membership beyond simply meeting network adequacy. Alternatively, if a provider has retired, s/he is also removed from the HSD provider files.

Moreover, MA provider directories now require the least amount of provider data elements than those required of any other federal program, such as Qualified Health Plans (QHPs) or Medicaid. CMS is closely watching the proposed provider directory regulations under Medicaid and QHP, and we believe the intent will be to propose similar requirements for provider directories across all government-sponsored health plans in the future.

CMS has recognized the elements below as best practices for MA plans and strongly encourages their inclusion in provider directories in advance of future rulemaking:

  • Machine-readable content
  • Provider’s medical group
  • Provider’s  institutional affiliation
  • Non-English languages spoken by provider
  • Provider website address

CMS is particularly urging MA plans to move towards some sort of machine readability for online provider directory content for accessibility for people with physical disabilities.  Since 2016, CMS has required plans in the federal exchanges to follow a handful of states that required state-run health exchange plans to publish machine-readable provider directory data in JSON (JavaScript Object Notation).  The goal has been to extend more transparency to a Qualified Health Plan’s (QHP’s) network for members during the selection process. CMS anticipates comparing the total number of providers in the network to the total number in a county or the Provider Participation Rate (PRR) and classifying planning into three categories: Standard, Broad and Basic.  Offering this type of comparison for MA plans could have a transformative effect on the network contracting strategy and provider partnerships.

 As CMS continues to move in the direction of a uniform evaluation for both network adequacy and provider directories across all government-sponsored health plans, plans should take advantage of the time afforded to develop a strong network strategy that takes into account the directory requirements, ensuring their provider agreements meet the clinical and financial goals of the organization and being proactive in aligning and understanding the needs of their largest asset, their providers. At MCS, we have a proven track record of helping plans assess and comply with current network compliance and the expertise to develop a robust network strategy that can carry your plan successfully into the future.

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Tags: CMS regulation, provider network,

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