Get Ready for Network Shock

1 Comment | Share | |

Have you submitted an application to CMS to expand your provider network lately?   If not, you may be in for a big surprise.  Inadequate provider networks have always been the number one reason CMS rejects Medicare Advantage (MA) applications. But in recent years CMS has raised the bar even higher. 

So what’s so new at CMS?  Here are just a few of the significant changes for networks:

• CMS has created totally new and rigid network adequacy standards for all MA Plans wanting to build or expand;
• Provider access time and distance standards now exist for every MA eligible county;
• CMS now defines the required contracted provider counts for every physician and facility specialty for each County;
• Minimum bed counts are now also required for hospitals and related services;
• MA Plans must contract with 35 physician specialties and 25 hospital and ancillary types to demonstrate adequacy to CMS;
• Ninety percent (90%) of the all Medicare beneficiaries in the county must be able to access every required physician and facility specialties using the time and distance standards;
• CMS commissioned new analytic software they use to calculate MA Plan’s network adequacy;
• The new software objectively determines if your network passes or fails.  If you don’t own or have access to this software you are at an extreme disadvantage;
• The applications from Plans failing to attain ninety percent (90%) adequacy in each of the 60 required provider specialties are now routinely denied;
• Your Application will be in jeopardy if even one physician or ancillary specialty fails to meet the new rigorous CMS standards.

Are your networks ready for CMS scrutiny?  If not, let GHG’s Provider Network team help you prepare.  We can analyze your network with Quest Analytics, the same software CMS uses.  Over the past decade, Gorman has assisted numerous health plans build CMS compliant networks.  We can meet your needs whether it is a full turn-key development or simply filling gaps in your existing network.

We invite you to contact us if you’d like to learn more about how Gorman can assist building a successful CMS compliant Network.


About CLyon

Craig Lyon brings to Gorman Health Group clients more than 25 years of experience in provider network development, physician group practice and contracting. Craig has worked with a wide variety of health care organizations including health plans, hospitals, medical groups, Independent Practice Associations (IPAs), Medical Service Organizations (MSOs) and related entities. Read more

One Comment

  1. Steve Pearse says:

    Does the software have content built into it to provide CMS with the exception counties.

    In Oregon we have several counties where there are under 10 providers and CMS always has trouble understanding that. Also we have several counties where it is not uncommon for medicare eligible to drive 50 to 75 miles to see a PCP. and, in some cases several hundred miles to see a specialist. The last time (4 yrs ago) when I submitted a service area expansion documentation, we had to provide extensive documentation proving that it was the standard level of care in the eastern part of the state.


Leave a Reply

Your email address will not be published. Required fields are marked *


You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>