The CMS is not backing down on its proposal to ensure payers in Medicare Advantage (MA) provide current and accurate information about their provider networks. In its plan, which needs the approval of the Office of Management and Budget (OMB), the CMS is demanding more review over MA provider networks to ensure provider information is up to date.
In comments on the proposal, insurers asked for more clarity on what network changes would require notification of CMS and asked for the new regulations to be implemented over three years. CMS declined those suggestions, Modern Healthcare reported.
Though turning aside most payer concerns, the CMS did agree to give them 60 days notice to submit their provider networks to a federal database instead of the initially proposed 30-day notice.
Currently, the CMS can only review MA plans’ provider networks when there is a triggering event, such as an insurer starts in MA, a payer expands its MA coverage or after a complaint about provider network issues. So, in effect, the CMS may never review a payer’s provider directory after the insurer first enters the market.
Earlier this year, the CMS found that 45% of MA provider directories had incorrect information, including which providers were taking new patients, wrong phone numbers and incorrect addresses. The agency likely wants to address the problem before the MA market gets much bigger. Payers are seeing positive financial numbers from MA plans, and last month UnitedHealth Group said it believes eventually half of all Medicare beneficiaries will be in MA plans.
If OMB approves the request, the CMS said it will have the opportunity to provide “timely compliance monitoring.” The CMS would review the provider information annually to make sure the payers are complying with offering a minimum number of providers and giving current and correct information. The plan would allow the CMS to take action against MA payers with incorrect information, including penalties or even freezing the payer’s MA enrollment.
The CMS believes the added oversight will resolve an issue with MA provider networks. The Government Accounting Office (GAO) spoke out about the issue in 2015. The GAO had concerns about the size of MA provider networks and incorrect online provider directories, including having providers listed as accepting new patients who had left the network, moved or even died. At that time, GAO suggested the CMS have more oversight over MA provider networks.