CMS Tells Medicare Advantage Plans to Fix Provider Directories


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 During an in-depth review of Medicare Advantage (MA) provider directories, the Centers for Medicare & Medicaid Services (CMS) found numerous directory inaccuracies. The federal government is now warning insurers that they must clean up their act. The CMS previously revealed some results of the review, focused predominantly on primary care physicians, cardiologists, ophthalmologists and oncologists. But in January 2017, the CMS released its final report stating that out of the 5,832 providers in the review, 46.9% had at least one type of deficiency.

The Results of the CMS Final MA Report

The final report included the names and results of the 54 health plans involved in the audit review, as well as the compliance actions taken against them. The average error rate among the plans reviewed was 38%. WellCare Health Plans, EmblemHealth and Piedmont Community Health Plan had the highest error rates in their provider directories. Each of these insurers received a warning from the CMS with a request for a business strategy describing how they plan to fix the problems that were identified in their directory.

 In addition to those three warning letters, the CMS sent out 31 notices of non-compliance and 18 warning letters to other health plans involved in the review. However, two insurers, the Kaiser Foundation Health Plan and CommunityCare Managed Healthcare Plans of Oklahoma, had lower rates of inaccuracies than the rest of the plans. These plans were the only two in which the CMS took no compliance action.

Deficiency Types and Directory Inaccuracies

The common deficiency types found by the CMS included:

  • The provider should not be listed in the directory at this location
  • The provider should not be listed in the directory-indicated locations
  • Phone number was wrong or disconnected
  • Address was incorrect
  • The provider is not accepting new patients

 The CMS found that the most common reason for directory inaccuracies is a group practice listing a provider at a location because the group has an office there, even if that provider never sees patients at that location. Additionally, the CMS revealed that most Medicare Advantage plans seem to rely heavily on credentialing services, vendor support and provider responses to ensure their directory accuracy, instead of internally overseeing it.

 The agency also noted that there were several cases where a call to a provider’s office resulted in finding that the provider had been retired or deceased for an extended period of time, sometimes even years. In other instances, the CMS discovered incorrect information that providers had verified themselves when the Medicare Advantage plans directly called them.

CMS Takes Action

As a result of numerous directory inaccuracies, the CMS is giving Medicare Advantage plans with deficiencies 30 days to make the required changes to achieve compliance. The agency is suggesting that these plans look into short-term solutions, for example conducting self-audits of directory data, working with group practices to ensure that providers are only listed at locations where they take appointments and developing a better internal process to report directory errors. If insurers fail to correct the directory errors, they could face penalties such as a suspension of Medicare Advantage plan marketing and enrollment.

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