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Is Dr. Smith in my network? MA enrollees want directories they can count on

During the early part of the decade, I was at the US Center for Medicare and Medicaid Services (CMS) where I headed a group that oversaw the Medicare Advantage (MA) program. At the time, MA provider directories really weren’t on our radar. But these electronic directories have come under scrutiny recently, and CMS is now conducting audits to help ensure the information is up to date and correct.

I was recently part of a panel discussion on provider directory accuracy at a Medicare and Medicaid conference sponsored by America’s Health Insurance Plans (AHIP). Given that nearly 20 million people are now enrolled in an MA plan, it is important that the directories can be relied upon. We are not there yet.

Accurate provider data is essential for value-based care
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) moves Medicare away from the traditional fee-for-service (FFS) model to one aligned with value. The law creates a financial incentive for health plans to figure out how to improve the management of their provider data so that they are able to track physician performance.

Value-based care and provider directories are tightly linked, and I see flawed directories as a symptom of a larger problem. The data, rather than the directory itself, are likely the real issue. The ability to track provider performance for risk-based contracts depends on having a solid provider data-management system. Without one, an MA plan isn’t able to accurately measure a physician’s performance against established benchmarks, which could cause challenges for value-based contracts. Inaccurate directories might also indicate that the MA plan has a limited level of engagement with its network physicians (close connections are essential for value-based care to succeed). Moreover, directory errors can make it difficult for beneficiaries to locate a doctor, or determine whether a physician office is accepting new patients. Frustration among members could surface in star ratings if those feelings are reflected in survey data.

Narrow networks make directories more vital
As MA plans work to contain rising costs, some are considering a move to tighten their provider networks. That strategy has often proven effective for products sold through the public health insurance exchanges. Narrow-network plans sold through the exchanges are an average of 16 percent less expensive than plans (on the same metal tier) that have broader networks, according to a study published in the September issue of Health Affairs.

While traditional Medicare is known for its broad provider access, more than one-third of MA beneficiaries are enrolled in a narrow-network MA plan (i.e., less than 30 percent of physicians in a county), according to an October report from the Kaiser Family Foundation. On average, MA networks include less than half of the physicians in a county, according to the report.

With fewer network providers, beneficiaries typically rely on directories to determine whether their doctor is in an MA plan’s network. Moving to narrow networks could also trigger network adequacy challenges for MA plans. Health plans that want to maintain or improve their star ratings should ensure that network providers are engaged and are helping maintain accurate directory information.

Strategies for keeping directories current
Information included in provider directories is in a constant state of flux as offices change locations, and as physicians retire or switch to other practices. A new paper from the Deloitte Center for Health Solutions and Center for Financial Services highlights the potential of blockchain technology for keeping directories current, accurate, and detailed. Blockchain is sort of a shared electronic ledger that could allow providers and insurers to quickly update data. If a provider changes networks, or if someone finds a mistake, they can initiate a correction, which can be automatically accepted or rejected by smart contracts based on other information in the blockchain, such as a recently rejected claim. If provider directory blockchains could be linked to other data, such as physician disciplinary actions (e.g., probation and/or suspended or revoked licenses) and physician death notices, the provider directory data could be even more useful and accurate.

Here are a few other strategies MA plans can consider to improve the accuracy of their provider directories:

  • Develop a structured, on-going process to monitor directory accuracy: Consider a risk-based methodology that mimics CMS’s directory monitoring protocols. Include additional provider types that go beyond those monitored by CMS.
  • Conduct an end-to end review of how provider data are managed: During these reviews, some health plans have identified a need to upgrade their provider data systems and/or self-service portals.
  • Use a single source of data: To demonstrate network adequacy, MA plans must submit directory and network information to CMS. In complying with this requirement, MA plans should avoid submitting data from multiple sources. Leading practices also include regular (monthly) checks of provider data, and MA plans should follow a risk-based approach that mimics the one used by CMS.
  • Offer providers multiple channels to update directory information: MA organizations should consider a wide variety of approaches – phone calls, emails, newsletters – to compel providers to keep their data up to date. A physician office that works with numerous health plans could be inundated with requests, and each request might seek information in a slightly different format. To help simplify this process, health plans should ask providers how they prefer to submit information. Some providers might find it easiest to update information through a web portal that can be accessed by multiple health plans.

Ensuring accuracy is as much of a burden on health plans as it is on health systems, hospitals, and physicians. Health care providers are already under pressure to comply with state and federal regulations and requirements, which can include provider-enrollment requirements, fraud and abuse requirements, and training. While CMS has been vocal about its efforts to reduce administrative burdens on providers, it is moving forward with approaches to help ensure the accuracy of provider directories.

CMS recently reviewed 5,832 providers at 11,646 locations and identified inaccurate information for nearly half (47 percent) of the providers listed in MA directories. As CMS increases its focus on provider directories, I’m hopeful that greater collaboration between MA plans and physicians will open more communication channels that will make it easier to help ensure the accuracy of directories.

Author bio

Danielle Moon is a Senior Advisor to Deloitte Consulting LLP’s Government Programs Practice. She joined Deloitte after 17 years at the Centers for Medicare and Medicaid Services, where she held a series of senior executive roles, culminating in oversight of the Medicare Advantage program. As a member of the CMS senior leadership team, Danielle engaged with senior executives of national and regional insurance companies, Pharmacy Benefit Managers, and health care providers on Medicare program compliance, contracting, network adequacy, bid review, quality improvement, enrollment and policy matters.