GAO criticizes oversight of Medicare Advantage network adequacy

GAO criticizes oversight of Medicare Advantage network adequacy

The rules governing Medicare Advantage Organization (MAO) networks lack certain elements to ensure that beneficiaries are able to acccess care in a timely manner, according to a new report.

To encourage network adequacy, the Centers for Medicare & Medicaid Services (CMS) established criteria that put a premium on the number of providers in a network. However, such criteria ignore measures of provider availability, the Government Accountability Office (GAO) report finds.

Because CMS does not consider whether an MAO’s contracted providers are part-time, for instance, provider networks may appear more robust to regulators and consumers than they actually are, the report states.

Additionally, CMS does not require MAOs to demonstrate network adequacy compliance every year; the agency instead performs reviews of network adequacy for only a fraction of MA networks through information provided by MAOs. So, CMS has no real way to determine MAO networks fully meet criteria.

GAO also called for greater standardization of how CMS notifies enrollees of provider termination in advance, pointing out that MAO notification letters lack certain pertinent information consumers need to make informed decisions.

To improve its oversight of MA network adequacy, GAO recommends that CMS verify provider information from MAOs and require MAOs to submit their networks for regular assessment. 

The Centers for Medicare & Medicaid Services previously announced that starting next year, health insurers must provide up-to-date doctor lists for their Medicare Advantage and policies.

Overall network adequacy also is a topic of concern for the National Association of Insurance Commissioners, which is currently working to improve the regulation of narrow networks, FierceHealthPayer previously reported. 

For more:
– here’s the report (.pdf)

Related Articles:
CMS tightens provider directory rules for 2016
State insurance regulators take on narrow-network debate
Government audits reveal millions in Medicare Advantage overpayments
Amid billions in recoveries, Medicare Advantage problems still linger

via GAO criticizes oversight of Medicare Advantage network adequacy


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