CMS Intensifies Provider Directory Penalties: 2019 Draft Call Letter

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The Centers for Medicare and Medicaid Services (CMS) requires plans to monitor and conduct regular updates of their provider network data, including updating providers’ ability to accept new patients, as well as their office address, phone number and any other changes that affect availability. Medicare Advantage (MA) plans must contact providers every three months and […]

2016 Provider Directory Accuracy & Network Adequacy Requirements

Pre-2016 Medicare Advantage network adequacy guidance simply states that plans must maintain a network of providers “sufficient to provide adequate access to covered services to meet the needs of the population served” and establish written rules on timeliness of access to care in accordance with CMS standards. Of course, this ambiguity has led to numerous […]

2017 MA Final Call Letter: Provider Directory Requirements Update

The 2017 Final Call Letter to Medicare Advantage Organizations (MAOs) continued to emphasize the importance of provider directory accuracy and the increased monitoring and enforcement actions to commence due to preliminary data collected via the PNA Pilot Program that found severe violations with the Part D and Part C requirements. CMS stated, however, that they […]

CMS Strengthens Provider Directory Standards

Beginning January 1, 2016, CMS will be strengthening their benchmarks for provider network data. This is due to a year plagued with consumer complaints regarding misleading provider network data in addition to CMS audits that have uncovered massive errors rates in provider directory resources. A series of high-profile health plan lawsuits have further brought attention […]