Reprinted from December 4, 2018, article in Modern Healthcare


Federal audits of Medicare Advantage plans' provider directories have revealed sweeping inaccuracies for the third straight year, raising the specter of fines or other penalties for the insurers.

Nearly 50% of provider directory locations showed at least one mistake in the latest audit results, the CMS said late Friday. Those errors included the wrong location, phone number or the directory claimed the listed provider was accepting new patients when they weren't.

The agency looks at about one-third of Medicare Advantage plans every year since the audits started under the Obama administration.

John Weis, president of Quest Analytics—a firm that started as a contractor with Medicare Advantage plans to evaluate network adequacy and has since moved into work on provider directories—said the problem is systemic and all plans deal with the "same burdens."

He expects the CMS to start imposing monetary penalties, but he doesn't know how heavy they will be. The agency suggested it would take that tack in its notice of 2019 Medicare Advantage rates and policies.

"CMS is giving plans a lot of leniency because they understand it's not a problem that will solve itself overnight," said Linda Borths, also of Quest Analytics. "Getting the system cleaned up is going to take a lot of effort."

The agency told Modern Healthcare that officials sent out 18 noncompliance notices, 15 warning letters and seven warning letters with a request for a business plan, but no fines as yet.

The plans have 30 days to correct the compliance issues that the CMS outlined for them in these notices.

"CMS expects all (managed-care plans) to conduct a comprehensive review of all their provider directories," a CMS representative said.

America's Health Insurance Plans, the trade group representing a substantial swath of Medicare Advantage business, ran its own initiative in three states to try to improve the system.

In 2017, AHIP released its analysis that concluded providers have a responsibility too, but that also pointed out a systemic flaw: There's no central place to update a provider's information for all the contracted health plans.

The CMS also noted this issue in the audit report, where the agency said "it has become clear that a centralized repository for provider data is a key component missing" for the directories.

AHIP also echoes the CMS' criticism that group practices often list information for the group rather than the individual physicians within the group, resulting in a mismatch of office hours or location for a particular doctor.

Basic communication methods are also problematic, AHIP said, but plans "are committed to continuing to work together with providers and CMS to identify more meaningful solutions for improving accuracy rates."

"It's garbage into the system at the beginning, which is causing all this havoc from the plans," Weis of Quest Analytics said, adding that he's found about one-fifth of the provider information changes every year.

View the full article.

by Susannah Luthi