CMS push­ing to take a closer look at Medi­care Ad­van­tage net­works

Modern Healthcare - - NEWS - By Vir­gil Dick­son

The CMS wants more au­thor­ity to en­sure that Medi­care Ad­van­tage plans aren’t cre­at­ing nar­row net­works that ul­ti­mately limit a ben­e­fi­ciary’s ac­cess to care.

The agency last week pro­posed that Medi­care Ad­van­tage plans upload the de­tails of their net­works to a cen­tral fed­eral data­base for re­view if they haven’t un­der­gone an en­tire re­view in the pre­vi­ous three years. The re­quest must be ap­proved by the White House’s Of­fice of Man­age­ment and Bud­get be­fore it can be im­ple­mented.

“This (pro­posal) is es­sen­tial to ap­pro­pri­ate and timely com­pli­ance mon­i­tor­ing by CMS,” the agency said in a no­tice.

Cur­rently, the CMS can only eval­u­ate a plan’s net­work when a so-called trig­ger­ing event oc­curs, such as when a plan starts op­er­at­ing un­der Medi­care Ad­van­tage, it ex­pands cov­er­age of­fer­ings to new ar­eas or the CMS re­ceives a com­plaint that a net­work is in­ad­e­quate.

But even in those in­stances, some­times the agency can only con­duct a par­tial net­work re­view. The CMS may re­view a se­lect set of spe­cialty types or coun­ties rather than re­view­ing the en­tire net­work with all spe­cialty types and coun­ties.

The Gov­ern­ment Ac­count­abil­ity Of­fice has found in the past that the CMS needed to do a bet­ter job en­sur­ing that there are ad­e­quate net­works fol­low­ing ev­i­dence that some plans had been nar­row­ing ben­e­fi­cia­ries’ choices for providers.

Ev­ery Medi­care Ad­van­tage plan that is due for its three-year en­tire net­work re­view will re­ceive a let­ter from the agency that will spec­ify which con­tracts will be ex­am­ined, the rea­son for the re­quest, a de­scrip­tion of the CMS’ net­work ad­e­quacy re­quire­ments and in­struc­tions on how to upload their net­work in­for­ma­tion. Those let­ters will be sent to plans that have not had an en­tire net­work re­view in the pre­vi­ous 12 months.

Ap­prox­i­mately 304 Medi­care Ad­van­tage plan con­tracts will re­ceive the ini­tial re­view re­quest, the CMS es­ti­mated.

If the CMS finds net­work de­fi­cien­cies, the in­surer may be sub­ject to en­force- ment ac­tions, in­clud­ing civil mon­e­tary penal­ties or an en­roll­ment freeze.

The CMS in Jan­uary re­vealed that a re­view found 45.1% of Medi­care Ad­van­tage plans’ provider di­rec­to­ries were in­ac­cu­rate.

For that re­port, the agency ex­am­ined the on­line provider di­rec­to­ries of 54 Medi­care Ad­van­tage plans, which rep­re­sent ap­prox­i­mately one-third of all Ad­van­tage plans. The re­view was con­ducted be­tween Fe­bru­ary and Au­gust 2016. Com­bined, the plans have a net­work of 5,832 providers.

The in­ac­cu­ra­cies ranged from the provider not be­ing at the lo­ca­tion listed, wrong phone num­bers and the list­ing in­cor­rectly not­ing the provider was ac­cept­ing new pa­tients.

Be­fore sub­mit­ting the re­quest to the OMB, the CMS is col­lect­ing com­ments on the pro­posal through Aug. 18.

Since 2004, the num­ber of ben­e­fi­cia­ries en­rolled in pri­vate Medi­care plans has more than tripled from 5.3 mil­lion to 17.6 mil­lion in 2016, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion.

The Gov­ern­ment Ac­count­abil­ity Of­fice has found in the past that the CMS needed to do a bet­ter job en­sur­ing that there are ad­e­quate net­works fol­low­ing ev­i­dence that some plans had been nar­row­ing ben­e­fi­cia­ries’ choices for providers.

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