The 2017 Final Call Letter to Medicare Advantage Organizations (MAOs) continued to emphasize the importance of provider directory accuracy and the increased monitoring and enforcement actions to commence due to preliminary data collected via the PNA Pilot Program that found severe violations with the Part D and Part C requirements. CMS stated, however, that they have purposefully not prescribed the means by which plans must update their provider directories in order to leave room for innovation, leaving huge opportunity on the table for software developers to step in and create new, automated systems for monitoring directory data compliance, conducting accuracy checks and performing provider directory data validation.

What the 2017 Call Letter did specifically prescribe is that Medicare Advantage (MA) plans should begin to include the following elements into the production of their directories in advance of future rulemaking:

• Provider medical group
• Provider institutional affiliations
• Non-English languages spoken by providers
• Provider website address
• Accessibility for people with physical disabilities

The encouraged inclusion of these new data elements is a result of an influx of sponsor comments CMS received in support of harmonizing the provider directory requirements across MA, QHP and Medicaid plan types. While MA has historically had the least prescriptive provider directory requirements, CMS is striving to gradually evolve them to be as explicit as the Medicaid and QHP requirements in order to create uniformity. While CMS works with their QHP and Medicaid counterparts to develop the official revised provider directory data elements for MAOs, they urge plans to incorporate the five elements listed above that they have found to be appropriate for current directory integration.

In additional effort to create requirement standardization across program, CMS is urging MAOs to look to the guidance provided by QHPs and Medicaid to identify a standardized format for machine readable information because while Medicaid and QHPs have moved to some level of machine readability for online directories, MAOs have not.

Another significant development is that MA plans must now institute a “warm transfer” policy. This means that when an enrollee calls a MA plan’s call center requesting help finding a provider, the CSR is to the close the call by transferring to the caller to the provider’s office to make an appointment.

In addition, CMS stated that they will:

• Use data collected from the PNA Pilot Program monitoring process to drive additional reviews and monitoring and/or audit-based activities and establish specific enforcement actions for identified areas of deficiency
• Extend PNA Pilot Program into 2017 to give themselves more time to gather and incorporate feedback from the sponsors who took part in the audit as per the July release of the 2017 Audit Protocols while also giving plans more time to assess and restructure their provider network managements systems

Finally, CMS continues to encourage plans to work collaboratively with providers to develop more effective and efficient methods for verifying and updating data to maintain accurate provider directories, and reminds Medicare-Medicaid Plans (MMPs) that they will be required to resubmit the Medicare medical provider and facility portion of their network information in September 2016 to evaluate network adequacy.

While the PNA Pilot Program monitoring processes remain at the forefront, it’s clear that the goal of CMS is not to cause undue burden or impose unnecessary civil money penalties— it is to develop clear, consistent and implementable directory compliance protocols that will enable MA plans to deliver timely and adequate access to care to beneficiaries and accurate information to MA caregivers responsible for making informed healthcare decisions.

Reference: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf