Imagine if each time you entered an address into your GPS you only had a 50% shot that you would arrive at your correct location. You would be pretty upset if you weren’t in the 50% that made it to their destination. That is precisely what CMS has uncovered during round two of the online provider directory review. The average Medicare Advantage Organization’s inaccuracy rate by location was 48.39%. Nearly HALF of all directory locations reviewed are inaccurate. That high rate not only produces frustration, but a significant access-to-care barrier for members.
It’s clear that healthcare payers do not have the necessary monitoring and oversight built into their system to be compliant. Sure, it would be great for a central provider database to be available, but it’s not. Which means the responsibility is on the healthcare payer to work with their providers to ensure accurate data. Payers can’t assume that every time a provider needs to update their information that they will reach out. A proactive outreach program must be put in place by the payer to obtain new data and ensure current data is correct. Using contract execution or renewal dates is a great place to start. Incorporating outreach that is triggered on an annual basis by these dates can jump start the monitoring process.
And location is only one element of a larger problem. During CMS’s review they also found a number of providers who had either retired, were deceased or relocated for a number of years. Inaccurate provider directories impact the overall adequacy of a payer’s network. After round 2 of the review, 23 plans were issued a notice of non-compliance, 19 plans were issued warning letters and 12 were issue warning letters with a request for a business plan. It’s time to be proactive and change the way you do things. Don’t become a statistic and receive a letter from CMS, instead issue a letter to your providers that contains the data you have on file and encourage a response. Work together to see better results.
Appointment of Representative, (aka the AOR) always seems to be a topic of conversation in the healthcare payer space. Every show we attend, every customer we talk with and every industry function we attend, there are intense conversations and differing opinions on what is required by CMS. Do you only submit an AOR once? Do you need to submit a […]
As part of an initiative to streamline the Medicare Advantage and Prescription Drug appeals and grievance processes, CMS has consolidated Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. They are doing this to better align and provider a more defined, straightforward and non-repetitive understanding of […]
5…4…3… 2…1 🚀, it’s time to move forward and discover the power of you! This is the message behind the 5 Second Rule by Mel Robbins. It’s a cool, powerful self-help concept I was introduced to while listening to Mel speak recently at Hyland Software’s CommunityLive event in Nashville, TN. Embracing that concept I say 5…4…3… 2…1 it’s time to […]
Does your contracting process take forever? Can it take weeks, even months to bring a contract from creation, through negotiation and finally to execution? What causes the bottlenecks and how can they be fixed? First, let’s identify some common hurdles within the contracting process. Once identified, we can implement a contracting management solution to address those issues and reduce contracting […]