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CMS Continues to Threaten Fines for MA Plans with 'Egregious' Provider Directory Violations
CMS Threatening Fines

Wednesday, April 17th 2019

The Centers for Medicare and Medicaid Services (CMS) issued its Medicare Advantage 2020 Final Call Letter on April 1. Page 192 of the letter addresses provider directories. Among other things, the 2020 Call Letter emphasized that, “the accuracy of [Medicare Advantage Organization] MAO provider directories continues to be a concern for the agency. Inaccurate provider directories may impede access to care and bring into question the adequacy and validity of the MAO's provider network.”

While not specially addressed in the 2020 letter, the agency's 2019 call letter specified that Civil Money Penalties (CMPs) and other enforcement actions could be imposed on MA plans with provider directory violations. Plans that have received a non-compliance notice for egregious violations and have failed to make corrections will be subject to these monetary penalties at any time.

Snapshot of the Problem

The quality of a health plan's provider data impacts its ability to remain compliant and avoid hefty fines. It also impacts a plan's ability to service its members. Provider directory errors anger members who rely on that data to make appointments and get directions. These errors also prevent members from accessing services that are critical to their health and well-being. In addition, data inaccuracies cast doubt on the adequacy and validity of the plan's network as a whole, deteriorating trust in the plan and lessening member engagement.

The Backstory

Beginning in February 2016, CMS undertook a study that examined the accuracy of the information in MAOs' online directories over the course of three years, or review rounds. CMS reviewed approximately one-third (between 50 and 60) of MAOs each year. The goal is to gain a better understanding of provider directory accuracy, identify best practices, and, through appropriate compliance actions, drive industry improvement in providing more accurate provider directories.

The first review, completed in 2016, found that 45% of provider locations listed in online directories were inaccurate. CMS noted that its findings were not skewed by a few organizations, but instead were widespread in the sample reviewed.

The review identified the following as primary reasons for directory errors:

  • Group practices provide data at the group level rather than the provider level.
  • Directories contain an inflated number of locations where the provider practices.
  • A general lack of internal audit and testing of directory accuracy.
  • Too many instances where providers were deceased or retired.

The second round of reviews, completed in 2017, revealed worsening results. This round found that 53% of provider locations listed in online directories had at least one of the following inaccuracies:

  • The provider was not practicing at the location listed or not accepting patients at the location.
  • The phone number was incorrect or disconnected.
  • The provider was not accepting new patients when the directory indicated they were.
  • The provider was not accepting the health plan at the location.

Similarly, the third round of reviews, completed in 2018, continued to show dreadful, albeit slightly better, results. This round of reviews found that 49% of provider locations listed in online directories had at least one error.

CMS calculated the percentage of locations with inaccuracies for each MAO directory, which ranged from 4.6% to 93%. The average MAO inaccuracy rate by location was 45%. The majority of the MAOs had between 30% and 60% inaccurate locations. Because MAO members rely on provider directories to locate an in-network provider, these inaccuracies could pose a significant access-to-care barrier. Inaccuracies with the highest likelihood of preventing access to care were found in 42% of all locations. In response to these findings, CMS-issued compliance actions intended to drive industry improvement in the accuracy of provider directories for MA beneficiaries.

A New Solution to a Complex Problem

Without the development of creative solutions that can improve directories with minimal administrative burden or provider abrasion, directories will continue to be a complex problem. Current phone and fax-based data validation methods are old-school and no longer effective. Health plans need modern digital tools that can simplify the data curation, enrichment and governance process.

One such tool is ProviderLenz from Curatus (formerly Animas Data Solutions). ProviderLenz, the company's flagship technology platform, curates and disseminates enriched provider data in real-time and behind-the-scenes for ALL payer use cases based on a single 'source of truth' Master Provider Index. This means that all operational areas within a payer's organization are always using the same and most up-to-date provider data available. All this is achieved with a single vendor and with no changes to a payer's current IT infrastructure.

Here's how it works:

First, Curatus receives provider and claims data from the health plan, which it ingests into the secure ProviderLenz platform. The data is converted into a standard format to be mapped to universal codes, allowing the data to be used for numerous applications.

Next, the data is placed into the Master Provider Index where it is compared and validated by numerous public and private datasets, correcting data particles along the way while enriching the data by adding missing elements and correcting errors. Once the data is curated, each element is graded by a proprietary scoring algorithm for accuracy and completeness. From there an Accuracy Confidence Level score is applied to each provider data file. Taken together, these graded data files inform health plan leaders as to the overall accuracy and reliability of their entire provider directory.

The curated, enriched, and scored data is then ready to be used across multiple operational areas within a health plan, including:

  • Provider directories,
  • Network adequacy compliance,
  • Risk analytics,
  • Quality metrics,
  • Shared savings reconciliation,
  • Encounter reporting, and
  • Claims adjudication.

Additional information about the pervasive problem of inaccurate provider data and/or ProviderLenz can be found at

Download the ProviderLenzSM PDF

    Stay Informed:

      Want to Learn More About CMS Provider Directory Fines?

      The Centers for Medicare & Medicaid Services (CMS) found in a recent review that 45.1% of provider directory locations were inaccurate.

      2022-01-28T03:51:26+00:00April 17th, 2019|0 Comments
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