Featured Health Business Daily Story, April 13, 2016

MA Provider-Directory Errors Are Among Main Targets of New AHIP, CMS Pilots

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By James Gutman, Managing Editor
April 7, 2016Volume 22Issue 7

An insurer trade group’s new pilot project on verifying provider-directory information may not only improve the acknowledged inaccuracy of much current provider-directory information, but it also may reduce the need for burgeoning CMS efforts to crack down on directory errors in Medicare Advantage.

However, neither the pilot unveiled by America’s Health Insurance Plans (AHIP) on March 22 nor the Provider Network Accuracy (PNA) monitoring pilot that CMS said in a March 16 memo it is developing are likely to lead to the nationwide MA provider-network database CMS officials had said in the past that they were considering. Wary of the huge resources that assembling such a database could require and the sheer difficulty of keeping information current even if it were established, both private and government efforts now seem to focus on just updating information and correcting errors in provider directories as quickly as possible. Perhaps with this in mind, CMS in its Feb. 19 “45-day notice” for 2017 MA plans dropped any language about a “national provider directory” and instead referred to a “machine readable” directory as its goal.

The AHIP pilot, which is not limited to any particular product such as MA, will be in three states — California, Florida and Indiana — and involve 12 member insurers. It will run six months (April to September), the trade association said, and “is designed to facilitate one primary point of contact for providers when updating or reporting changes to their practice information.”

Medicare Advantage News

AHIP says its pilot incorporates recent regulatory changes related to network directories. It cites as an example a 2016 MA requirement for quarterly outreach to providers to verify key directory data. Asked by MAN at the news conference unveiling the pilot whether the project’s success could end CMS’s own exploration of how to develop a source of updated provider-network information in MA, Jeanette Thornton, AHIP’s senior vice president for health plan operations and strategy, replied only that CMS is aware of what the trade group is doing in the pilot and why. She called the pilot “the first step toward a comprehensive solution” and noted AHIP never has done anything like this.

The AHIP members participating in the pilot and the states where they will participate are Anthem, Inc. (California and Indiana), AvMed (Florida), Blue Shield of California, Cigna Corp. (Florida), Florida Blue, the Health Net unit of Centene Corp. (California), Humana Inc. (California, Florida and Indiana), LA Care (California), Molina Healthcare of California, SCAN Health Plan (California), WellCare Health Plans, Inc. (Florida) and Western Health Advantage (California).

Two vendors, “chosen through a competitive selection process” and working via different approaches in different states, will have key roles in the pilot, according to AHIP, which declined to disclose the cost of the project. BetterDoctor will work with plans in California and Indiana, primarily using phone calls to validate information with providers, although it also will utilize emails to drive “providers to an online profile and fax outreach,” the trade group said. Availity will handle Florida and will furnish alerts asking providers to “validate their information within Availity’s existing provider portal,” but it also will conduct phone and email outreach directing providers to update information within the portal.

The data that providers will be asked to verify, according to AHIP, include address, phone number, fax number, specialty, whether they are accepting new patients, insurance network status and medical group and hospital affiliations.

More Than 100,000 Providers May Participate

AHIP added that both vendors will update information in their own centralized database and make the updates, including details about non-responsive providers and non-working numbers, available online for all participating health plans. The trade group estimates that more than 100,000 providers will participate in the pilot and notes that other AHIP member plans can join during the course of the six months.

Limiting participation to AHIP members means that two of the largest MA insurers, UnitedHealth Group and Aetna Inc., which used to belong to the group but ended their memberships within the past couple of years, won’t be part of the pilot. Asked about this by MAN in the news conference, AHIP President and CEO Marilyn Tavenner said the project would consider adding those companies in the future if there was interest.

The pilot drew applause from 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. “Assuming things go well, everyone wins,” Adelberg says.

But there also are limitations to what AHIP is doing, he adds. For instance, “the pilot is more a useful service to health plans than a national provider database,” Adelberg tells MAN, and “the pilot cannot correct human error, of which there is a lot. Think of all the times you’ve called a doctor’s office and received incorrect or incomplete information.”

So if this pilot is so limited, what else should health plans be doing on the issue? Adelberg responds that they should, “at the very least, be looking at their provider contracts and assuring that they can incent providers to keep directories current. They should also be looking at their directory error rate and measuring improvement. We know CMS is.”

That’s not all CMS is doing on the directories. The agency, in the March 16 memo sent via the electronic Health Plan Management System (HPMS), says the PNA pilot “will test the accuracy of the data in a sponsor’s provider directory as well as in their Health Service Delivery (HSD) tables, but will not actually evaluate the adequacy of a sponsor’s network.” The PNA pilot will involve the use by CMS’s Medicare Parts C and D Oversight and Enforcement Group (MOEG), according to the group’s director, Jerry Mulcahy, of the results of monitoring efforts by the Medicare Drug & Health Plan Contract Administration Group (MCAG) to “audit and validate correction of any deficiencies identified throughout the year.”

Specifically, the HPMS memo continues, “MCAG will be selecting a number of contracts and calling providers in those contracts’ provider directories to ensure that the provider” still has a contract with the MA plan and that other information in the directories about the provider is correct. This pilot will be separate from 2016 program audits and won’t be “administered as a normal audit protocol.” If it finds errors, the memo explains, MCAG will notify the MA plan sponsor and instruct the sponsor to correct those errors.

MOEG will wait at least 30 days after such notification and then will validate that the sponsor’s directory “and corresponding HSD tables have been updated and reflect accurate information.” If the sponsor involved continues to have errors, the MA plan may be “subject to possible enforcement action, including civil money penalties or enrollment sanctions,” the memo says.

View the CMS memo by visiting the April 7 From the Editor entry at MAN's subscriber-only Web page: www.aishealth.com/newsletters/medicareadvantagenews.

© 2016 by Atlantic Information Services, Inc. All Rights Reserved.


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