Directory & Provider Data: How Small Inaccuracies Could Lead to Big Risks

For the past year, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data Integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and potentially sanction. As we saw last year with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. Now is the time to set new ongoing network monitoring processes in place that ensure your CMS network submissions and Health Service Delivery (HSD) tables mirror your online provider directories, guaranteeing you are prepared to address provider and member complaints stemming from directory inaccuracies.

A recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS’ oversight and enforcement of Medicare Advantage (MA) network requirements and recommended greater scrutiny of the plans’ networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.

For MA plans who currently have the least stringent directory requirements of all government-sponsored health plans, this means plans are only required to outreach to the providers on a quarterly basis to validate the following information is correct:

  • Provider’s ability to accept new patients,
  • Provider’s street address,
  • Provider phone number, and
  • Any other changes that affect availability to patients.

Although seemingly straightforward, when coupled with several other nuances, the task becomes daunting and, in some cases, an operational impossibility. Real-time updates to provider demographics, grievance resolution, reconciliation of provider location, and notation of individual providers accepting new patients are a few examples of where a simple requirement can reveal so many gaps and pose so much risk. Inefficiencies capturing, storing, and governing provider data at the onset of the contracting and credentialing processes is a place to start, but what about the historic legacy information that needs to be sanitized? Add the individual specifications and data requested by and delivered from industry vendors and delegated entities, risk adjustment, the Healthcare Effectiveness Data and Information Set (HEDIS®), behavioral health, and the large, delegated provider and academic groups that should be providing the plan with a current roster each month – this is no small task.

At this point, you might be asking yourself:

  • How do we bridge the gap between understanding our compliance risk and deploying a successful change in operations to ensure the loop is closed and successfully maintained at every point in the contract life cycle?
  • How do we ensure vendor partners are supporting us and aligning their business practices with both the regulatory requirements and our key performance indicators for Star Ratings, risk adjustment, care management, and member experience?
  • Is it possible to fix my content management system as it exists today, or do I need to rip and replace?

Gorman Health Group (GHG) can answer these questions, and we encourage you to follow along with us as we explore these questions and how they relate to the results from the first CMS pilot audit. Next week, we will provide in-depth detail on the operational and cross-functional elements of how this regulatory change will impact the entire industry. We’ll have commentary from several leading vendors in the industry and dig deeper into the downstream implications provider data inefficiencies can have on your plan as a whole. In the meantime, please contact us directly if you have questions or would like to schedule a time to meet with one of our industry experts to discuss how GHG can support your efforts to avoid risk and improve results.




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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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