In-network providers are the only feasible choice for many patients due to the high cost of going out of network. That’s presumably why CMS is hot on the trail to find and correct inaccurate online provider directories, and to monitor provider accessibility and provider network adequacy standards. For egregious service location enrollment errors, it doesn’t appear that CMS is taking the tack of automatically disenrolling groups/providers without notification, but it reserves that right.

“Surprise billing” is related hot-button issue—occurring when insured members of a network get unexpected bills for obtaining care from providers falsely listed as in-network when they are not.

You could say that Medicare Advantage Organizations (MAOs) collectively earned a failing grade on CMS’ Medicare Advantage (MA) online provider directory reviews, reported in the Online Provider Directory Review Report. It was not a small or insignificant sample. In three rounds of reviews, CMS covered 37,000 locations and +18,000 providers. The latest check targeted four of the most commonly used provider types: cardiologists, oncologists, ophthalmologists, and PCPs.

CMS flatly stated, “The findings suggest that MAOs are not adequately maintaining the accuracy of their provider directories.” The concerns: At a minimum, discrepancies frustrate members. At worst, frequent inaccuracies prevent sufficient access to care and shed doubt on the adequacy and validity of the MAO’s network as a whole.

Direct patients at provider level, not group practice level

Providers benefit from being listed in payers’ directories in that it affords them opportunity to increase practice volume. However, patients rely on networks directories for accuracy. CMS warned that it sees group practices wrongly publishing data at the group level rather than at the provider level (i.e., the group has an office at the site, even if that specific provider rarely or never sees patients there).

What isn’t addressed specifically in the report—the “just in case” scenarios employed by some healthcare organizations whereby they enroll providers into multiple (or all) of their service locations, even sites where the practitioner may never provide care or services. Others simply don’t have a good handle on keeping their directory data accurate. Those issues substantiate CMS’ finding that location inaccuracy (specifically, “provider not practicing at location”) is the most common error. It’s also weighted most heavily in terms of deficiency scoring by CMS. Another common error: Stating that providers are accepting new patients when they are not.

How CMS checked up

CMS can conduct directory checks inexpensively to provide a lot of return in the form of data. Third-party call centers directly dial out to practices using the site’s own directories or rosters to request a specific provider. When met with the response that the provider doesn’t practice at that location, trouble can ensue in the form of penalties and enrollment sanctions.

The questions posed on the calls:

  1. Does the provider see patients at this location?
  2. Does the provider accept the MA-PD plan at this location?
  3. Does the provider accept (or not accept) new patients who have this MA-PD plan? (The provider directory is considered accurate if it correctly indicates if the provider is or is not accepting new patients.)
  4. Is the provider a (PCP, cardiologist, oncologist, or ophthalmologist)?
  5. Is the address correct?
  6. Is the telephone number correct?
  7. Is the provider’s name correct?
  8. Is the practice name correct?

In the third and most recent round of checks (about 11,000 locations and 6,000 providers), CMS found:

  • 55% of provider directory locations are inaccurate.
  • 55% of providers have at least one deficiency.
  • 60% of errors identified are where the “Provider is not practicing at location.”
  • The majority of Medicare Advantage plans have between 30 and 60% inaccurate locations

Sharing Results with MAOs

CMS shared the initial findings with each organization, including the inaccuracies found in the provider directories, granting an initial response period of two weeks. After review of that corrected data, organizations ultimately had 30 days to make all necessary corrections in the directory.