In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback. While it was a stressful 24 hours pending the Centers for Medicare & Medicaid Services (CMS) response on the notice, we hope the false alarm sparked the much needed jump-start to ensure a compliant network adequacy monitoring program is in place.
Unfortunately, we know fire drills do not often produce the continued preparedness needed. Ask kids who grew up in the northeast how many times they shivered in the cold when a fire alarm went off and they did not grab their jackets! Oftentimes, we get busy with pressing contract negotiations or deadlines and push preparing or incorporating a new process off to the side. However, with the shift in network adequacy from an application function to a plan operational requirement, plans that fail to meet network adequacy requirements will be subject to compliance/enforcement actions such as being suppressed from Medicare Plan Finder for the upcoming Annual Election Period until deficiencies are cured or ensuring access to care by allowing members to see an out-of-network provider at in-network cost-sharing. Additionally, the short time frame in which a plan will have to submit their compliant HSD tables to CMS leaves little to no time to mitigate network deficiencies by contracting with new providers and/or doing the detailed research required to validate filing an exception. CMS as well as many states have put sanctions and monetary and enrollment penalties in place for deficiencies in network adequacy and directory accuracy. Plans no longer have a grace period to put off ensuring a compliant network monitoring program is in place.
CMS indicated they will provide plans selected for the network review 60 days’ notice prior to the June submission date. By my calendar, April is just a few days away, and June will be approaching fast. Do not let April Fool’s Day prank you with network gaps. Be prepared, and let’s start spring with a bounce in our step and a plan of action!
At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but also develops a comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.
Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now
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