Providers could be making their patients more susceptible to balance or surprise billing because they're not doing enough to ensure their network directories are accurate, according to some experts.
For the second year in a row, the CMS estimates that Medicare Advantage provider networks are plagued with inaccurate information. The agency found 52% of the provider directories it reviewed had at least one mistake, such as a wrong address or phone number or wrong information on whether the provider was accepting new patients. Last year, the agency found that 45.1% of provider directories of a different group of Medicare Advantage plans it reviewed were not accurate. As a result, the CMS issued 23 notices of noncompliance and 31 warning letters this year.
"Directories are critical for consumers both in choosing and using a plan," said Betsy Imholz, director of special projects for Consumers Union. "If you think you've used in-network care, but it turns out to be out-of-network there will be a nasty surprise bill."
Last year, the CMS cited mostly traditional commercial insurers as opposed to this year when mostly Medicare Advantage plans overseen by healthcare systems or national hospitals chains were dinged. Johns Hopkins Healthcare, New York City Health & Hospitals, Providence Health & Services, Catholic Health Initiatives and Baptist Healthcare System were some of the organizations put on notice.
"Traditional insurers have felt the heat over the issue," said Simon Haeder, a healthcare policy professor at West Virginia University, adding they've taken corrective action. "I am not sure that provider organizations have the resources to follow suit, or whether they have shown enough interest."
Experts say the growth in provider-sponsored plans put more patients at risk of balance billing, while the CMS is concerned about how mistakes affect access to care. In 2015, there were 270 plans owned by health systems, up from 107 two years ago, according to an Atlantic Information Services survey. Membership in those plans increased from 32.8 million in 2014 to 36.2 million in 2015.
The CMS analyzed 64 Medicare Advantage plan directories that included 6,841 providers across 14,869 locations. Within each Medicare Advantage plan directory, the percentage of mistakes in locations average 48.3%.
"The report is a black eye for our industry," said John Gorman, a former CMS official who is now a healthcare consultant in Washington. "It's easy to fix. We have to do better."
Networks were often inaccurate because group practices provide data to plans at the group level and not at the provider level, according to the CMS. Group practices tend to list a provider at a location because the group they work for has an office there but a specific provider may not practice there.
The CMS also found that Medicare Advantage plans lack internal audit procedures to confirm accuracy of networks and some simply never update their networks. The agency said some calls to a provider's office revealed a doctor had been retired or dead for years.
The CMS is putting added pressure on fixing these mistakes as Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.
The CMS is conducting the third review round, which will examine online provider directories of an additional 50 Medicare Advantage plans. That report, like the last two, will be released early next year.
