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CMS wants more power to review MA provider networks

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The CMS wants more review power over  Medicare Advantage (MA) provider networks to ensure that they “provide adequate access to covered services to meet the needs of the population served.” Next month, it will formally request that the Office of Management and Budget (OMB) approve the plan.

Currently, CMS only reviews MA plans’ networks when there is a triggering event – e.g., when an insurer starts in a Medicare Advantage plan, when it expands its MA coverage or after a complaint about network issues. Translation: If an MA payer doesn’t expand its offerings or the CMS doesn’t receive any complaints, an MA plan’s provider directory might never get reviewed after first entering the market.

Assuming that the OMB approves the proposal, the CMS could act against MA payers that have incorrect information, including fining the insurers or freezing their enrollments.

Healthcare Dive notes that the Government Accounting Office (GAO)  has expressed concerns “about the size of MA provider networks and incorrect online provider directories, including having providers listed as accepting new patients who had left the network, moved or even died. GAO suggested the CMS have more oversight over MA provider networks. ‘’

“In January, the CMS found that 45% of MA provider directories had incorrect information, including which providers were taking new patients, wrong phone numbers and wrong addresses.’’



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