Two-Thirds of Providers Aren’t At Listed Locations, CMS Finds

The pilot was launched this year in response to beneficiary complaints, congressional inquiries and other sources prompting the agency to enhance its oversight of provider networks, including the accuracy of directory information provided to beneficiaries (MAN 4/7/16, p. 1).

“Provider directories are simple tools used to connect beneficiaries and their caregivers to your contracted providers so that they can get the care that they need,” asserted Jeremy Willard, technical advisor with the Division of Surveillance, Compliance, and Marketing within MCAG, at the conference. “The accuracy of that information is paramount for that happening. If any of that information is wrong, they’re not able to get to that contracted provider.” But based on its recent review, CMS found that when a beneficiary chooses a provider via a plan’s online directory, there is a 46% chance that something is inaccurate.

MCAG 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, or more than 5,800 providers with multiple locations for a total of 11,646 locations. Contractor Booz Allen Hamilton contacted nearly 6,000 providers to verify certain information such as provider names, practice names, street addresses and whether the provider works at the location listed and accepts the selected plan at that location.

The CMS contractor conducted the review in a transparent manner, explaining the purpose of the call to the providers, stated Willard. The information collected by the contractor was then sent back to CMS via a spreadsheet containing all the data elements, which CMS reviewed. CMS then shared the initial deficiencies identified with the plans. Plans were given two weeks to issue a response, in which they were asked to concur or disagree and provide additional information in areas with which they did not concur.

CMS found some common problems with the plan responses, such as failing to actually verify the information that was flagged as inaccurate, relying on source data alone and issuing “cut and paste” responses for the sake of time, said Willard. Furthermore, he suggested that plans improve their provider-level data vs. simply including information about the location of a group practice. “Our expectation is that plans put their best foot forward as far as reviewing the data,” he said. “We really want you to do what is necessary to hear from the provider themselves, [to] get solid responses if you are disagreeing with us.”

Once a final determination on the deficiencies is made, plans are notified and have 30 calendar days to make the requested changes, such as removing a provider from the online directory if the entity is not at that location or accepting new patients. In Phase II of the pilot, CMS will validate that the deficiencies have been corrected and the directory has been properly updated, and when applicable, will look at Health Services and Delivery tables “to see if providers have been removed appropriately,” said Willard.

Nearly Half of Locations Had Errors

Of the 11,646 total locations reviewed, CMS identified 5,257 locations (46%) with deficiencies, meaning at least one or more items in the directory pertaining to that location was inaccurate, and a total of 5,352 final deficiencies, disclosed Christine Reinhard, health insurance specialist and technical advisor with the same division at CMS. While there were a couple of outlier organizations that did extremely well or had an extraordinary number of deficiencies, the bulk of organizations had online directories that were 20% to 60% inaccurate.

CMS excluded practice names from its report on the final deficiencies. Reinhard said the initial review turned up “hundreds if not thousands of inaccurate practice names,” but pointed out that CMS doesn’t have firm requirements on the exact meaning of “practice name” and that it’s rather nuanced considering there could be four doctors at a practice but it’s not necessarily misleading to list the names of all four doctors instead of its proper practice name.

One finding that was particularly surprising to Reinhard and her team was the abundance of listed providers that were found not to be at their locations. This occurred in 3,544 instances, accounting for 66.2% of all deficiencies. “We had providers that had been retired for years still in the directory, providers that had passed away over a year ago or more, [and] we had a lot of provider practices that said, ‘I don’t even know who this person is. He or she has never worked here,’ so that was a surprise to us,” she revealed.

The other four most common errors, in descending order, were:

• Inaccurate phone number, which occurred 521 times, or 9.7% of all deficiencies. And CMS found that in most instances these were disconnected or out-of-service phone numbers. In some cases, the number turned out to be a physician’s cell phone and there were even a few calls that went to beneficiaries.

• Incorrect address, which happened 450 times, or 8.4% of all deficiencies. Reinhard suggested this was potentially more egregious than a wrong suite number, because in the case of the former, the patient is at least in the right building.

• Provider is not accepting new patients, which happened 338 times, or 6.3% of all deficiencies. Reinhard said CMS recognizes this can be a “fluid item” in the directory. “While we did look at this, we were pretty lenient on those deficiencies because providers do change, possibly month to month, [and] this is one of the areas that is a little more difficult to keep to date.”

• Incorrect address-suite number, which occurred 221 times, or 4.1% of all deficiencies.

In addition, CMS is concerned about the number of providers who were not aware of their contracted status with the provider organization. “Especially when you expand or add providers to your network, please make sure you educate those providers about the acceptance of your plan,” she advised.

CMS Considered Link to Network Adequacy

CMS in its review also considered the implications of provider directory errors on network adequacy, and asked the parent organizations if they used the same underlying database for their online provider directories as for their HSD tables. The majority of plans said they do, reported Reinhard. “With so many providers not being where they’re listed, we are concerned that that’s going to have an effect on HSD tables,” she told attendees. “Given that a provider may practice at five locations and four of them are correct and one is incorrect, that’s going to have less of an effect vs. a provider that’s listed at 10 locations and eight of them are incorrect and the provider’s not actually there. So it’s something to consider and be aware of.”

CMS Is Still Weighing Compliance Approach

According to the March 16 memo that told plan sponsors of the pilot, if the selected plans’ directories continue to show deficiencies, they may be “subject to possible enforcement action, including civil money penalties or enrollment sanctions.” Reinhard said CMS has not taken any actions, but that it will weight the deficiencies based on egregiousness (i.e., reflecting CMS concerns about a provider not being at a location vs. an inaccurate suite number). “If there’s more than one deficiency, we are not making a cumulative weighting. We’re taking the most egregious deficiency and counting it as the weight of that most egregious [finding] and not adding other deficiencies,” she explained. Compliance actions can result from Phase I or Phase II and CMS is “still working on that,” she added.

Moreover, CMS recognizes that there are challenges with keeping online provider directories up-to-date and that not all data are going to be 100% accurate all of the time, said Reinhard. But a 46% inaccurate rate is “unacceptable,” she said, and given the importance of the directory for beneficiaries, CMS expects that accuracy must improve.

View a replay of the session at www.youtube.com/watch?v=TPgv9k0TZCc.

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