In a survey released last January, the Centers of Medicare and Medicaid Services (CMS) revealed that 45% of Medicare Advantage Organizations (MAOs) had inaccurate provider directories. In response, CMS has issued a statement requesting for stronger oversight over online provider directories.
What this means for MAOs is that they will need to step up their game by creating more accurate provider directories. However, the plan sponsors face significant challenges complying with the new mandate. In a January report, CMS uncovered some surprising information:

  • In over 1,000 of the cases, the provider associated with the locations in the directories did not work at any of the locations. For example, if a provider is listed in 3 locations in the directory, CMS found them at 0 of these locations.
  • 541 instances where the provider’s phone number was incorrect or disconnected.
  • 338 times the online directory stated the provider was accepting new patients, when they found out that they were not.
  • CMS found some cases where the providers had been dead for years

To put the whole report into perspective, CMS considers that 85% of the deficiencies identified contained outstanding errors that are likely to impact MAO members access to care. These findings raise some troubling concerns for CMS and the MAOs. If plan sponsors can’t reliably state which providers are in their network, how can they meet the needs of plan beneficiaries?

Currently CMS only reviews a MAOs provider directory when there is an event such as a MAO starts in Medicare Advantage, expands its MA coverage, or after a complaint about network issues. However, in response to their January report, CMS is requesting the Office of Management and Budget (OMB) for more insight to review how often and with what accuracy MAOs review and update their provider networks. If CMS request is approved, MAOs that have not had an entire review by CMS in the last 3 years will need to submit their networks to a federal database.

To prepare for these changes, Medicare Advantage Organizations will need to update their internal processes. Here are some proactive steps MAOs can take to stay compliant:

  • Develop a single source of truth for all provider data
  • Adopt a centralized, cloud-based approach to data consolidation and plan creation across the organization
  • Automate the creation of provider directories by using master templates, versioning, and variable business data across plans
  • Eliminate manual processes by using data to automate the provider directory creation
  • Take the initiative – don’t assume that provider networks will update you with their change of information

MAOs that are able to maintain accurate provider directories have better opportunities to remain compliant with CMS while also delivering a better customer experience.

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