Reprinted from the February 1, 2018, issue of AIS Health’s Radar on Medicare Advantage (formerly Medicare Advantage News)

CMS last month posted the results of its second year reviewing the online provider directories of Medicare Advantage organizations, and plan sponsors appear to be no better than they were last year at updating the listings, despite CMS’s efforts to strengthen existing sub-regulatory guidance and share best practices from its initial review of directories. Findings from the new report include that plans are continuing to post listings with the same frequently identified inaccuracies and that the average MAO inaccuracy rate by location was 48.39%, compared with 41.37% identified in last year’s report. Nevertheless, CMS has yet to impose fines on any offenders.

“The trends of the second-year review are alarming,” says John Weis, CEO of Quest Analytics LLC, which assists MA plans in building provider networks. “I would have anticipated the inaccuracy rates of the first-year reviews to have brought a heightened awareness and increased focus from the industry. Reviewing the second-year results exposes two disturbing trends: the systematic epidemic of industrywide data inaccuracies, and the challenges in maintaining accurate data. Perhaps the carrot approach isn’t working. I wouldn’t be surprised for the third-year review to carry more teeth for non-compliance.”

The CMS Medicare Drug & Health Plan Contract Administration Group (MCAG) launched the directory accuracy initiative in 2016 largely in response to beneficiary complaints, congressional inquiries and the Government Accountability Office prompting the agency to enhance its oversight of provider networks, including the accuracy of directory information provided to beneficiaries.

MCAG for the pilot phase selected 54 parent organizations to review, and focused on 108 providers evenly split between four provider types (primary care physicians, oncologists, ophthalmologists and cardiologists) for one randomly selected contract per organization. Of the 11,646 locations reviewed between February and August 2016, 45.1% had at least one deficiency.

For the second round of reviews, which were conducted between September 2016 and August 2017, CMS examined the accuracy of 108 providers and their listed locations selected from the online directories of 64 MAOs, or one-third of MA sponsors. This amounted to a total of 6,841 providers reviewed at 14,869 locations, of which more than half (52.2%) had at least one inaccuracy, according to the Jan. 19 “Online Provider Directory Review Report.” Of those locations reviewed, providers should not have been listed at 33.15% (4,929) of the locations either because the provider did not work at the location or because the provider did not accept the plan at the location, observed the report.

Within each MAO directory, the percent of inaccurate locations ranged from 11.20% to 97.82%, with an average inaccuracy rate by location of 48.39% across the MAOs reviewed, added CMS. This differs from the overall inaccuracy rate of 52.20% because some MAOs had multiple locations listed for individual providers, resulting in many more locations for these MAOs, according to the report.

Listings Include Same Common Errors

Like last year, CMS observed that the majority of the MAOs (37 of 64) had between 30% and 60% inaccurate locations. And CMS again found that common errors included the provider not being at the listed location, incorrect phone numbers and the provider not accepting new patients when the directory indicated they were.

“Because MAO members rely on provider directories to locate an in-network provider, these inaccuracies could pose a significant access-to-care barrier,” CMS reminded MAOs. Inaccuracies with the highest likelihood of preventing access to care were found in 45.64% of all locations, compared with 38.4% estimated in the prior year report.

CMS in the report made no mention of any civil monetary penalties imposed on plans with high rates of directory accuracy errors and only said it issued “appropriate compliance actions,” including 23 notices of non-compliance, 19 warning letters, and 12 warning letters with a request for a business plan. The agency in last year’s report said it advised MAOs in the warning letters that, if unable to bring their directories into compliance in a timely manner (e.g., within 30 days from receipt of the letter), “CMS may consider taking additional compliance actions, including a formal request for a corrective action plan (CAP), or taking enforcement actions in the form of the imposition of intermediate sanctions (e.g., the suspension of marketing and enrollment activities) or civil money penalties.”

“For a lot of good reasons directory accuracy is hard, but the CMS report demonstrates that progress was not made during Year 2 of oversight. Year 3 is underway — this could be the year that CMS moves beyond warning letters for the worst performers,” observes Michael Adelberg, a principal with FaegreBD Consulting.

CMS intends to monitor all MAOs over the course of three years, or review rounds, by examining approximately one-third of all MAOs each year. The agency is now in its third round of online provider directory reviews, which will examine the directories of 50 MAOs, said the report.

Providers Are Unaware of Plan Needs

A separate report released last year by America’s Health Insurance Plans (AHIP) illustrated the difficulties plans face when attempting to update and verify directory information. The findings, which were based on the outreach efforts of 13 plan participants and evaluated by NORC at the University of Chicago, concluded that providers demonstrated a general lack of awareness regarding the need to proactively alert plans of changes and/or respond to requests from plans and that they weren’t always aware of the federal and/or state regulations requiring plans to have accurate, up-to-date directory information.

Industry Lacks Directory Standards

The AHIP report suggested that one “national solution” to maintaining better directories would be the development of an industrywide set of standards for provider directory data definitions or other validation standards. CMS had expressed interest in developing a nationwide MA provider-network database, but in its 2017 Advance Notice and Call Letter for MA and Part D plans dropped any language from the draft notice about a “national provider directory” and instead expressed its support for plans’ use of new technologies — including those that capitalize on machine-readable information — in simplifying their process of updating provider directories.

Meanwhile, other research conducted by NORC suggests that accuracy of information remains a problem. Tim Riddle, director of product innovation and development at NORC, remarks: “The data are not as accurate as they could be. And they’re inaccurate across product offerings and geographic areas; it’s an industry challenge to work together to find a solution.”

The latest CMS report identified several “common drivers that may be contributing to provider directory inaccuracies,” including:

Group practices continuing to provide data at the group level rather than at the provider level. “To ensure that beneficiaries can connect with the contracted providers at the location listed, it is critical that the provider directory does not convey an inflated number of locations where the provider practices,” stated CMS.

A general lack of internal audit and testing of directory accuracy among many MAOs. This likely reflects an overreliance on credentialing services and vendor support, and CMS suggested that MAOs instead implement “routine oversight of their processes for data validation.”

Information for a provider’s office that appears to have been outdated for a long time. MAOs cannot assume that they will be informed when a change in provider location occurs, advised CMS. And the agency stressed that MAOs “need to implement routine processes that drive more accurate information reflected in their directories” and proactively reach out to providers for updated information on a regular basis. “They should actively use the data available to them, such as claims, to identify any provider inactivity that could prompt further investigation,” added CMS.

Other suggestions offered by CMS included performing self-audits of directory data, working with group practices to ensure that providers are listed only at locations where they accept appointments, and developing better internal processes for members to report directory errors. CMS added that it is “encouraged by several ongoing pilot programs aimed at developing a centralized repository for provider data accessible to multiple stakeholders.”

View the report at

by Lauren Flynn Kelly