2016 Medicare Advantage Call Letter Requires Medicare Advantage Plans to Maintain Updated Provider Directories

Today, the Centers for Medicare and Medicaid Services (CMS) released the 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter.

As you may recall, ASCRS advocated for many changes in this letter, urging CMS to address the narrowing of networks within Medicare Advantage Organizations (MAOs). ASCRS also asked CMS to prevent terminations of providers without cause and ensure that provider directories are accurate and up-to-date.

In the final letter today, CMS clarified that Medicare Advantage Organizations are expected to update their online provider directories in real time, meaning they must make changes when they are notified of changes in a providers' status or when the plan itself makes changes to its network of providers. Additionally, CMS clarified in this final Call Letter that MAOs are expected to communicate with providers monthly regarding their network status.

CMS noted that MAOs are expected to "establish and maintain a proactive, structured process that enables them to assess on a timely basis, the true availability of contracted providers which includes, as needed an analysis to verify that the provider network is sufficient to provide adequate access to covered services for all enrollees." CMS defines an effective process as including regular, ongoing communications with providers to ascertain their availability and a protocol to address inquiries related to enrollees being denied access to a contracted provider.

To comply with regulations, MAOs must include in their online provider directories all active contracted providers, with specific notations to highlight providers who are closed or not accepting new patients. CMS will enforce MAO compliance through direct monitoring, a new audit protocol that will be tested in 2015, and compliance and enforcement actions for MAOs that fail to maintain accurate directories.

CMS stated in this call letter that they are considering requiring MAOs in the future to provide and regularly update network information in a standardized electronic format that can eventually be used to create provider directories at the state level and in national databases.

ASCRS will continue its advocacy efforts to urge CMS to address no-cause terminations of providers in MAO networks. Additional information will be included in Washington Watch this week. If you have any questions, please contact Ashley McGlone, manager of regulatory affairs at 703-591-2220.