Featured in Health Business Daily, August 22, 2017

CMS Provider Directory Review Results In 21 Warning Letters; Fines Could Follow

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. Subscribe today!

By Lauren Flynn Kelly, Managing Editor
January 26, 2017Volume 23Issue 2

The official results of the first phase of CMS’s directory accuracy pilot are in, and of the 54 Medicare Advantage organizations (MAOs) whose online provider directories were reviewed, 21 this month received letters warning that if they fail to correct their deficiencies, they could be subject to enforcement actions such as fines. While one expert says warning letters are a relatively moderate outcome, he suggests CMS may not be so nice the next time around.

The CMS Medicare Drug & Health Plan Contract Administration Group (MCAG) launched the pilot last year largely in response to beneficiary complaints, congressional inquiries and the Government Accountabilty Office prompting the agency to enhance its oversight of provider networks, including the accuracy of directory information provided to beneficiaries (MAN 4/7/16, p. 1). MCAG selected 54 parent organizations to review, and focused on 108 providers evenly split between four provider types (primary care physicians, oncologists, ophthalmologists and cardiologists) for one randomly selected contract per organization. That amounted to a total of 5,832 providers reviewed (representing 11,646 locations) between February and August of 2016.

Each organization was given an opportunity to review CMS’s findings, concur or disagree with those findings, and provide documentation if they did not concur. CMS then made “final determinations” and, according to the Jan. 13 “Online Provider Directory Review Report,” found that 45.1% of provider directory locations listed in the online directories reviewed were inaccurate. Errors included the provider not being at the listed location, incorrect phone numbers and the provider not accepting new patients when the directory indicated they were.

Within each MAO directory, the percent of inaccurate locations ranged from 1.77% to 86.53%, with an average inaccuracy rate by location of 41.37% across the MAOs reviewed, said CMS. The majority of the MAOs (37 of 54) had between 30% and 60% inaccurate locations. “Because MAO members rely on provider directories to locate an in-network provider, these inaccuracies pose a significant access to care barrier,” emphasized CMS. Inaccuracies with the highest likelihood of preventing access to care were found in 38.4% of all locations. The differences in the severity of final deficiencies were reflected in a weighted scoring methodology, e.g., a provider location listing that indicated they are not taking new patients when they are received a weight of 1, while an incorrect phone number got a 3. A location with multiple types of final deficiencies was assigned a score that equaled the weight of the most significant final deficiency.

Medicare Advantage News

CMS May Take Additional Compliance Actions

The first completed phase of CMS’s monitoring effort resulted in 31 Notices of Non-Compliance, 18 warning letters and three warning letters with a “Request for a Business Plan.” CMS in each letter advised of the MAO’s “failure to maintain accurate online provider directories” and informed them of their final deficiency score (which ranged from 19.66% to 70.75%). Moreover, CMS advised them that, if unable to bring their directories into compliance in a timely manner (e.g., 30 days from receipt of the letter), “CMS may consider taking additional compliance actions, including a formal request for a corrective action plan (CAP), or taking enforcement actions in the form of the imposition of intermediate sanctions (e.g., the suspension of marketing and enrollment activities) or civil money penalties.” Those who received notices of non-compliance were simply told to ensure that their “provider directory information is accurate and up to date.” Two plans with very low deficiency scores did not receive any compliance action.

“The decision to issue warning letters, without imposing fines, could be seen as a moderate action from CMS, especially given the tone of the report,” observed Michael Adelberg, senior director at FaegreBD Consulting and a former high-level CMS MA official who had a leading role on network-adequacy issues there. “CMS might choose to be tougher next time around.”

CMS intends to monitor all MAOs over the course of three years, or review rounds, by examining approximately one-third of all MAOs each year. “The goal is to gain a better understanding of provider directory accuracy, identify any best practices, and, through appropriate compliance actions, drive industry improvement in providing more accurate provider directories,” stated the report. CMS is currently in the second round, in which it will review the online provider directories of 64 MAOs.

The report also identified several common drivers that it observed may be contributing to the directory inaccuracies. These are: (1) group practices appearing to provide data at the group level rather than at the provider level; (2) a general lack of internal audit and testing of directory accuracy among many MAOs; and (3) instances where a call to a provider’s office resulted in determining that the provider had been retired or deceased for a long period of time, sometimes years. MAOs cannot simply assume that they will be notified when a change in a provider location occurs and must take a proactive approach in validating provider directory information, stressed CMS.

View the report and a complete list of the reviewed plans and their scores at www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/index.html.


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