CMS to take closer look at Medicare Advantage provider networks

Medicare Advantage plans will face more frequent and consistent scrutiny under a new Trump administration directive.

Starting next year, the CMS will review Medicare Advantage provider networks on three-year cycles rather than only when a company applies to be or renews its status in the program. The agency will also conduct intermediate full network reviews under certain circumstances, such as when Medicare beneficiaries report access issues.

“The triennial review cycle will help ensure a consistent process for network oversight and monitoring,” the agency said in a notice on the White House website.

Some large players—like the Blue Cross and Blue Shield Association, which represents 36 Blues plans— pushed back on the policy change, as they wanted the CMS to consider phasing in the three-year network adequacy review for large Medicare Advantage organizations with many contracts. That approach would make the new policy less burdensome by not imposing a major data submission all at once on plans operating all over the country, according to the association.

But the CMS declined the request, noting that all Medicare Advantage plans must be held to the same standards in order to maintain a level playing field.

Currently, the CMS can only evaluate plans’ compliance with network adequacy criteria when a so-called triggering event occurs, such as when a plan starts operating under Medicare Advantage, expands coverage offerings to new areas, or the CMS receives a

There will be approximately 304 Medicare Advantage reviews next year.

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.

Unless a triggering event occurs and an entire network review is prompted, a Medicare Advantage plan’s network is not formally reviewed by the CMS after it first joins the program or begins to operate in a new region.

As part of the new method, Medicare Advantage plans will upload their networks to a central federal database for review if they haven’t undergone an entire CMS network review in the previous three years.

There will be approximately 304 Medicare Advantage reviews next year, the agency estimates. The CMS will notify all selected organizations at least 60 days before they must submit network data.If the CMS finds network deficiencies, the insurer may be subject to enforcement actions, including civil monetary penalties or an enrollment freeze.

The Government Accountability Office has found in the past that the CMS needed to do a better job ensuring that there are adequate networks for Medicare Advantage plans following evidence that some Advantage plans had been narrowing their provider networks.

In January 2017, the CMS revealed 45.1% of provider directories of Medicare Advantage plans reviewed were not accurate.

For that report, from February to August of 2016 the agency examined the online provider directories of 54 Medicare Advantage plans, or approximately one-third of all Advantage plans. Combined, these 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.

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.