CMS Threatens to Penalize Medicare Advantage for Inaccurate Provider Directories

By Bill Bunker, Executive Vice President, SCI Solutions

Understanding your insurance coverage is dependent on whether your provider is in-network or out-of-network on your health plan. To make that determination, patients and referring providers rely on insurance payer’s directories to see if the specific provider in question is listed. Simple enough? Not if the directories are out-of-date, an issue that patients and practices have recently run into.

Many Medicare Advantage and commercial carriers have made significant changes to their networks of doctors and hospitals over the past few years. In a recent Modern Healthcare article, Medicare beneficiaries say these directories list providers no longer contracted with an Advantage plan or still include in-network providers who have retired, moved locations, or passed away.

CMS stated that it “has become aware of a range of issues with online provider directories”. As a result, a new mandate requires payers to update their provider data at least four time per a year. In addition, CMS is conducting audits and threatening to punish plans not accepting new patients with civil money penalties or, in more extreme circumstances, enrollment sanctions.

So what does this mean for patients? According to PBS journalist and Medicare expert Philip Moeller, insurers will be responsible for developing a process to handle cases when members are denied access to a provider who is incorrectly listed as in-network. To ensure accuracy, patients should call the provider’s office directly to double check prior to their appointment. Even providers who were in-network in 2014 could change to out-of-network in 2015.

For practices, make sure your provider listings on currently and formally contracted payer directories are up-to-date. If there is a discrepancy, report it immediately. For specialty providers who receive referred patients, it is crucial to secure insurance pre-authorizations prior to your patient’s visit. This will confirm your patient’s insurance information is up-to-date and ensure you are paid for your work. To streamline this authorization process, many practices have outsourced this step to referral and insurance authorization experts who keep up payer changes.

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