To make sure there is current and accurate information, the CMS is requesting more review over Medicare Advantage (MA) provider networks “to provide adequate access to covered services to meet the needs of the population served.” The CMS is taking comments on the proposal until Aug. 18, when it will make a formal request to the Office of Management and Budget (OMB), which needs to approve the plan.
The CMS now only reviews MA plans’ networks when there is a triggering event, such as when an insurer starts in MA, expands its MA coverage or after a complaint about network issues. That means that if an MA payer doesn't expand its offerings or the CMS doesn't receive any complaints, an MA plan's provider directory may never get reviewed after first entering the market.
If the OMB approves the idea, the CMS could take action against MA payers that have incorrect information, including penalizing the insurer or freezing its enrollment.
In addition to needing to have correct information, MA plans need to offer a minimum number of providers and the maximum travel time and distance from enrollees to providers.
If approved, the CMS said it will have a chance to provide “timely compliance monitoring.” The CMS would review provider information each year to make sure the payers are complying.
Provider networks have been a concern for years.The Government Accounting Office (GAO) spoke out about the issue in 2015. 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. GAO suggested the CMS have more oversight over MA provider networks.
In January, the CMS found that 45% of MA provider directories had incorrect information, including which providers were taking new patients, wrong phone numbers and wrong addresses.
The CMS’ request comes as MA continues to grow in popularity. About one-third of Medicare beneficiaries are now on an MA plan and payers like UnitedHealth and Humana are looking to invest more in the program. UnitedHealth recently said it expects MA will one day have half of all Medicare beneficiaries.