The Centers for Medicare & Medicaid Services (CMS) turned things up a notch with new provider directory requirements last year, and now they’re doubling down with Corrective Action Plan requests for Medicare Advantage Organizations (MAOs) that aren’t playing by the rules. We’re breaking down the latest news about the added provider directory requirements and Corrective Action Plan requests.
How Does CMS Monitor Medicare Advantage Organizations?
CMS monitors MAOs throughout the year to ensure they comply with program requirements. They accomplish this through comprehensive monitoring activities that cover both operational and financial aspects. As part of this process, CMS periodically reviews the online provider directories to assess provider data accuracy. These reviews take place outside of the regular audit timeframe. When data discrepancies or inaccuracies are found, CMS will request a Corrective Action Plan from the MAO.
What is a Corrective Action Plan?
A Corrective Action Plan is a step-by-step plan of action developed to address identified errors and achieve targeted outcomes. It aims to:
- Identify the most cost-effective actions that can be implemented to correct error causes
- Develop and implement a plan of action to improve processes or methods so that outcomes are more effective and efficient
- Achieve measurable improvement in the highest priority areas
- Eliminate repeated deficient practices
In other words, a Corrective Action Plan is CMS’s way of saying, “Let’s fix this and make sure it doesn’t happen again.”
What Are the New Medicare Advantage Organization Provider Directory Requirements?
Now, let’s get into the reason we’re all here, reading this article today. Last year, CMS introduced new requirements for provider directories, leading to MAOs receiving Corrective Action Plan requests for failure to maintain accurate directories. Let’s take a quick look at the two new requirements.
1. Additional Provider Data Elements Must Be Verified and Accurately Listed in the Provider Directories
MAOs must include Cultural and Linguistic Capabilities, including American Sign Language, for each provider in their directories. These data elements were added on top of the existing requirements, and they should not be overlooked when updating the directory.
2. Provider Directories Must Be Searchable by Every Element Required in the Model Provider Directory
MAOs must make their provider directories searchable by every provider data element required in the model provider directory. Previously, the regulations left it up to each MAO to decide which elements to include in the search functionality. However, CMS recognized the importance of consistency and made it mandatory for all MAOs to adhere to this structure.
What Must Medicare Advantage Organizations Do When They Receive a Corrective Action Plan Request?
When an MAO receives a Corrective Action Plan request from CMS due to inaccurate provider directory listings, it has limited time—typically 30 days—to address the issues. Below is a list of what the MAO is expected to do.
- Correct the Provider Directory: Correct any inaccurate listings in the provider directory.
- Work with Providers: Collaborate with providers who must correct and update the required data elements.
- Create a Detailed Corrective Action Plan: Have a detailed plan that shows the steps the MAO will take to improve provider directory accuracy and the actions the organization will take to prevent inaccuracies from recurring.
Pro Tip: Show Work! Documentation of the MAO’s current provider verification process is key to showcasing your compliance efforts. Have provider outreach metrics readily available to demonstrate the efforts made to CMS.
What to expect from CMS provider directory compliance monitoring methods?
CMS’s compliance monitoring of MAO provider directories is about to get even stronger. MAOs will want to focus on aligning their processes with the requirements and having the data insights to explain their position to CMS if needed. The increase in oversight is to promote transparency and help consumers have trust in the insurance plan they purchased.
👉 Did You Know? Quest Analytics can help you during these times! Discover how we can assist you with provider data accuracy and network adequacy compliance.
How Can Medicare Advantage Organizations Avoid Receiving a Corrective Action Plan Request?
To avoid receiving a Corrective Action Plan in your inbox, here are a few key items to remember.
- Evaluate Your Process and Solutions: Double-check that your current provider outreach, verification, and data management efforts are keeping you compliant. If you need help reviewing your process, download our free worksheet.
- Include Extra Provider Data Elements: Don’t forget to verify specialty and cultural and linguistic capabilities.
- Make the Provider Directories Searchable: Ensure beneficiaries can search by all required elements, including cultural and linguistic capabilities.
CMS’s increased scrutiny of provider directories underscores the importance of maintaining provider data accuracy. Corrective Action Plan requests will continue to be a focus. By staying informed about the requirements, implementing necessary changes, and working with Quest Analytics, MAOs can maintain compliant and trustworthy provider directories.
That’s it for now but stay tuned for more industry insights and compliance know-how, right here at Quest Analytics.
