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Medicare May Penalize Advantage Plans for Faulty Provider Lists

Aimee Sharp
Author | Shield HealthCare
02/25/15  12:19 AM PST
Centers for Medicare & Medicaid Services

By Bob Herman for Modern Healthcare

The CMS plans to more closely monitor Medicare Advantage insurers’ provider networks and may fine or otherwise sanction plans that don’t accurately show which doctors are available at in-network prices.

New provisions related to provider networks and directories were included in the agency’s proposed 2016 rate notice (PDF), released last Friday. Medicare Advantage payments will drop 0.95% on average, but when accounting for higher risk scores based on coding patterns, health plans on average will receive a 1.05% increase.

Over the past few years, some Advantage carriers have made “significant changes” to their networks of doctors and hospitals during the year, said Gretchen Jacobson, a health economist and associate director at the Kaiser Family Foundation. UnitedHealthcare, the largest private Medicare plan operator, drew widespread criticism last year when it eliminated large numbers of providers from several of its networks.

For some seniors and doctor groups, the changes have come as a surprise and disrupted access to care, Jacobson said. Compounding the problem was the fact that many Medicare insurers did not update their list of in-network doctors, an issue that has been widespread among individual and commercial plans as well.

The CMS said in the notice that it “has become aware of a range of issues with online provider directories.” Medicare beneficiaries have complained of directories in which providers no longer contract with an Advantage plan, or directories still include in-network doctors who have retired, moved locations or died. Other online provider lists do not indicate if doctors refuse to take new patients.

Because of these problems, the CMS said it wants insurers to update provider data, such as contact information and whether doctors are accepting new patients, at least four times per year. Insurers will also have to correct mistakes in the online directories and develop a process to handle cases when members are denied access to an in-network provider.

Read the Full Article at Modern Healthcare.

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