Like Clockwork: Regular Data Management Keeps Members and Regulators Happy

Ensure Provider Data Accuracy Compliance and Optimal Outcomes - Read the Blog Post Regular Data Management Keeps Members and Regulators Happy

Building and maintaining an adequate Medicare Advantage provider network may seem tough–like chiseling something out of stone. But like Michelangelo, you can sculpt your network into a masterpiece that will stand the test of time. Continually monitoring your provider data will help you maintain network adequacy standards, creating a top-notch provider network that will increase member satisfaction and build trust in your plan.

Maintain CMS Compliance

What's the Latest with Provider Data Accuracy and Network Adequacy Oversight

Feeling the heat these days? We’re not talking about the fire from a burning kiln, but rather, the pressure from complying with the Centers for Medicare & Medicaid Services (CMS) increasing requirements. If you’re involved with a Medicare Advantage Organization (MAO), you understand the scorching angst that sets in when CMS is hot on your tail, combing through your Health Services Delivery (HSD) Tables like a forensic investigator.

In the past, CMS would most commonly1 audit your data every three years as part of the Triennial Network Adequacy Review. These days they inspect your HSD Tables for initial or expansion applications with a potential Triennial Review in the first year the contract is operational in the new service area.

The shift from random audits to annual reviews creates an even greater onus on you to actively watch your provider data and address any gaps before CMS knocks on your proverbial door. As provider information changes, contracts shift and holes appear, not only do regulators notice–so do members.

How to Prepare for Your CMS HSD Table Audit

Keep Your Eye on Excessive Provider Locations

You’ve heard it before: Location, location, location! But we’re not talking about houses, we’re talking about the provider addresses listed in your HSD Tables, and what you can do to prepare for your next CMS audit.

Paula Partin, Senior Director of QES Adequacy, reminds you that to be ready for an audit, you need to know which providers are listed in your data at an excessive number of locations—and you need to know sooner rather than later. By doing so, you give yourself more time to make any necessary changes to your data or provider network.

The Importance of Regular Provider Data Audits

Enhancing Network Quality, Member Satisfaction, and Insurance Plan Success

Speaking of members, maintaining an adequate network isn’t just about complying with regulations–it’s about building trust and loyalty. Just like how people travel from all over the world to see Michelangelo’s David, consumers will flock to your plan if they know they can count on high-quality care from reliable providers.

For members, having access to healthcare services nearby is more than just a matter of convenience. It’s about getting the care they need quickly, both in terms of distance and availability.

The aging population has even more significant barriers as they retire from driving and rely on public transportation or family members to attend appointments. If providers aren’t available, member complaints rise and satisfaction levels plummet. Star ratings? Remember, one is the loneliest number.

Regular provider data audits are a chance to ensure that your network consistently meets and even surpasses expectations. By detecting changes early, you can make the necessary adjustments to improve the quality of the network, remove irrelevant providers and update your directory. When you take these steps, you have a better chance to win the hearts of your members and build their confidence in your insurance plan-leading to higher retention rates and more success for you.

Provider Data Management Tips

Provider Directories and HSD Tables

Your provider network is your greatest strength, but a network with inaccurate data or ghost providers isn’t very efficient. Whether you’re fine-tuning your data for a Triennial Network Adequacy Review, or just want to avoid compliance issues throughout the year, we’ve got some super savvy tips to help. Follow our expert advice and you’ll turn heads with your impressive compliance skills.

Keep Your Provider Directories and HSD Tables in Sync

First things first, let’s talk about your provider directories and HSD Tables. If these two aren’t in sync, you’ll be in trouble quicker than a horse on roller skates. So, to make them snazzy and CMS-friendly, keep them accurate and synced.

Limit Your Provider Locations 

Now, let’s talk about those providers taking up extra real estate in your HSD Tables. We’re talking about the ones who seem to be listed all over the map (literally). Word on the street is that CMS is keeping a watchful eye on providers listed at a high number of locations. While there aren’t any concrete rules about it, we’ve heard some chatter about different numbers being thrown around. To be safe, limit providers to 5-10 locations.

Only Include Accessible Locations

According to the rule book, provider locations only count if a member can actually make an appointment with the provider at that location. Providers who fill in or float like a butterfly should not have a spot on your HSD Tables.

For facility specialties, verify that only addresses where a facility exists and is accessible to individuals in your service area are listed on the HSD Tables.

List Individual NPIs, Not Organizational NPIs

Make sure only individual NPIs2 are listed in your HSD Tables and not organizational NPIs. By doing this, you ensure that the provider data truly reflects the individual provider.

Check Your Addresses Against Your Provider Directories

Before submitting your HSD Tables, cross-check the addresses in the HSD Tables with your provider directories. Remove any NPI and location combinations that shouldn’t be included.

Assess Your Provider Network After Making Changes 

Finding out who’s who in your network and where they practice most often is just one part of the equation. Once you have identified and removed providers with excessive locations, it’s time to assess your network as you likely have a new gap. To stay in compliance, you’ll need to find a provider to close the gap quickly. Keep in mind that CMS expects you to correct your HSD Tables.

Shore Up Your Provider Data Management

Do More With Provider Data

Just like Michelangelo persistently improved his art, you can enhance your provider network even after it’s built. By frequently keeping an eye on your provider data, you can shape your network to be compliant and compelling. Above all, ensure that your members receive the exceptional care they need and deserve.

More On Provider Data Accuracy and Network Adequacy

Stay up-to-date on the latest developments and best practices in provider data accuracy with these valuable resources! We’ve rounded up some of the most helpful articles on current network adequacy and provider data accuracy rules to help you navigate the changing landscape. Dive in now!




1. The Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans: CMS monitors network compliance by reviewing organizations’ networks on a triennial basis. They expect that organizations continuously monitor their networks for compliance with the current network adequacy requirements. The triennial network adequacy review cycle helps to ensure a consistent process for network oversight and monitoring. In addition, CMS may perform a network review after specific triggering events such as:

  • Initial Application
  • Service Area Expansion (SAE) Application
  • Significant Provider/Facility Contract Termination
  • Change of ownership transaction
  • Network Access Complaint
  • Organization-disclosed Network Gap

2. NPI stands for National Provider Identifier and is the unique identification number for covered health care providers.

Proven Solutions for Your Provider Network Management

Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

Schedule Now