CMS seeks greater authority to vet Medicare Advantage networks

Updated​ July​ 21,​ 2017.

The CMS plans to request greater authority from the White House to ensure Medicare Advantage Plans have adequate provider networks.

Currently, the CMS can only evaluate plans' compliance with its network adequacy criteria when a so-called triggering event occurs, such as when a plan starts operating under Medicare Advantage, it expands coverage offerings to new areas, or the CMS receives a complaint that a network is inadequate.

But even in those instances, sometimes the agency can only conduct a partial network review. The CMS may review a select set of specialty types or counties rather than reviewing the entire network with all specialty types and counties.

Unless a triggering event occurs and an entire network review is prompted, a Medicare Advantage plan's network is not formally reviewed by the CMS after it first joins the program or begins to operate in a new region.

The CMS is proposing that Medicare Advantage plans upload their networks to a central federal database for review if they haven't undergone an entire CMS network review in the previous three years. The request must be approved by the White House's Office of Management and Budget before it can be implemented.

"This [proposal] is essential to appropriate and timely compliance monitoring by CMS," the agency said in a notice posted Wednesday.

The Government Accountability Office has found in the past that the CMS needed to do a better job ensuring that there are adequate networks for Medicare Advantage plans following evidence that some Advantage plans had been narrowing their provider networks.

Every Medicare Advantage plan that is due for its three-year entire network review will receive a letter from the agency that will specify which contracts are due for review, the reason for the request, a description of the CMS' network adequacy requirements and instructions on how to upload their networks. Those letters will be sent to plans that have not had an entire network review in the previous 12 months.

Approximately 304 Medicare Advantage plan contracts will receive the initial review request, the CMS estimates.

If the CMS finds network deficiencies, the insurer may be subject to enforcement actions, including civil monetary penalties or an enrollment freeze.

The CMS in January revealed 45.1% of provider directories of Medicare Advantage plans reviewed were not accurate.

For that report, the agency examined the online provider directories of 54 Medicare Advantage plans, which represents approximately one-third of all Advantage plans, between February and August of 2016. Combined, these plans have a network of 5,832 providers.

The inaccuracies ranged from the provider not being at the location listed, wrong phone numbers and the listing incorrectly noting the provider was accepting new patients.

Before submitting the request to the OMB, the CMS is collecting comments on the proposal through Aug. 18.

Since 2004, the number of beneficiaries enrolled in private Medicare plans has more than tripled from 5.3 million to 17.6 million in 2016, according to the Kaiser Family Foundation.

An​ edited​ version​ of​ this​ story​ is​ also​ in​ Modern​ Healthcare's​ July​ 24​ print​ edition.