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CMS tightens provider directory rules for 2016

Medicare Advantage, Healthcare.gov plans subject to stiff penalties

Starting next year, health insurers must provide up-to-date doctor lists for their Medicare Advantage and Healthcare.gov policies, according to the Centers for Medicare & Medicaid Services.

CMS sent a letter to issuers of qualified health plans (QHPs) on the federal marketplace and a separate letter to insurers that issued Medicare Advantage plans at the end of last month.

The first letter focused primarily on the certification process for QHPs as well as standalone dental plans that are sold on Healthcare.gov and the Small Business Health Options Programs (SHOP) sites.

"A QHP issuer must publish an up-to-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider's location, contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible," according to the letter to Healthcare.gov plans.

Issuers must update these directories each month and make them available in a machine-readable file and format, CMS said, "to allow the creation of user-friendly aggregated information sources."

The requirement comes after CMS received reports that many Affordable Care Act plan enrollees struggled to find doctors who would accept them as patients.

Meanwhile, the second letter focused largely on the CMS proposal to slightly decrease Medicare Advantage reimbursement rates for 2016. The proposal places added emphasis on improving care quality and customer service--and up-to-date provider directors represent an important part of that mission, FierceHealthPayer previously reported. 

Medicare Advantage organizations, CMS said, "are expected to establish and maintain a proactive, structured process that enables them to assess, on a timely basis, the true availability of contracted providers which includes, as needed, an analysis to verify continued compliance with applicable network access requirements." This includes contacting providers once every three months to verify contact information, as well as whether they accept new patients.

CMS added that it will consider a requirement to provide such directories in a standardized, electronic format, as is already required of QHPs that sell on Healthcare.gov.

In both cases, plans with directories that do not comply with the new CMS rules face stiff penalties--a maximum of $100 per day per individual adversely affected by a non-compliant QHP or dental plan and up to $25,000 per day per Medicare Advantage beneficiary, according to Kaiser Health News.

Reaction from the insurance industry was mixed, KHN said. America's Health Insurance Plans said it can be difficult for payers to receive information from providers "in a timely manner." Meanwhile, Aetna and Cigna told KHN that their Medicare Advantage directories are already updated more frequently than the new CMS rule requires.

For more:
read the letter (.pdf) to insurers on Healthcare.gov
- here's the letter (.pdf) to Medicare Advantage insurers
- check out the Kaiser Health News article

Related Articles:
CMS proposes slight decrease in Medicare Advantage rates for 2016
Report: Marketplaces can do more to improve transparency
OIG: Insurers' Medicaid provider directories are inaccurate
Insurers: Clean up your provider networks
Some ACA plan enrollees struggle to find docs