Beginning in 2019, the Centers for Medicare & Medicaid Services (CMS) will start reviewing Medicare Advantage Organizations (MAOs) on a triennial cycle. This is due in part to the results of the review CMS conducted in 2016 of provider directories, wherein 46.9 percent of providers reviewed had at least one deficiency and 45.1 percent of the locations reviewed had at least one deficiency. CMS issued a total of 31 notices of noncompliance, 18 warning letters, and three warning letters with a request for a business plan. Another impetus for the launch of the provider network reviews is recent evidence that plans have begun narrowing beneficiaries’ choices for providers.
Currently, the only way CMS can evaluate if a plan is meeting provider network adequacy criteria is when a plan starts operating as a MAO, a plan engages in a service area expansion, or CMS receives a complaint regarding provider network inadequacy. Unless one of these events occurs, there is no formal mechanism for CMS to review or conduct a partial review of MAOs’ provider networks.
CMS has developed criteria that set forth the minimum number of providers and maximum travel time and distance from beneficiaries to providers for required provider specialty types in each county in the U.S. and its territories. MAOs must be in compliance with the current criteria. The criteria are updated and published annually on CMS’ Medicare Advantage Applications website.
CMS’ goal in launching this every-three-years review cycle is to ensure adequate provider network oversight and validity, thereby ensuring that beneficiaries have no issues regarding access to care. The methodology for the review is that MAOs will upload their networks to a central federal database for review. CMS estimates that there will be approximately 304 reviews next year and they will notify all selected plans at least 60 days prior to due date for submittal. CMS will review all contracts that have not undergone a full network review since contract initiation within the first two years of this initiative by ensuring that they are included in the random sample of active contracts. Should CMS identify provider network deficiencies, the plan could be subject to enforcement actions, including civil monetary penalties or an enrollment freeze.
In February 2018, CMS will provide MAOs the opportunity to upload their network into the Health Plan Management System Network Management Module for an informal review.
To prevent your MAO from findings in either provider directory reviews or provider adequacy reviews, MAOs must begin including these areas as part of their annual risk assessment and incorporate auditing and monitoring of this area as part of their annual audit work plan.