GAO: CMS MA Efforts Fail to Uphold Provider Network Adequacy
By - The Administrator of the Centers for Medicaid & Medicaid Services (CMS) should make adjustments to the management of Medicare Advantage (MA) networks to tackle provider availability, validate MA organizations’ (MAO) provider information, execute more regular reviews of MAO network information, and establish requisites for MAO enrollee notification letters, according to a recommendation within a report from The United States Government Accountability Office (GAO).
The Department of Health and Human Services (HHS) agreed with such recommendations and says “it plans to take, or is considering to strengthen its oversight of MAO network adequacy.” Nonetheless, GAO confirms it is perhaps too soon to determine to what extent the acknowledged issues will be addressed.
MAOs can either instigate or close contracts with healthcare providers “at any time for any reason,” says GAO. This may pose especially problematic, according to the report. Apprehensions have recently arisen about MAO network criteria compliance and an alleged effort to water down provider networks, maintains GAO. Such may be interfering with enrollees’ ability to acquire access to care, the organization says.
Within its study, GAO interviewed numerous CMS officials, medical association representatives, and beneficiary advocacy group persona to acquire deeper insight regarding recent MAO provider network information. GAO assessed to what extent CMS is warranting MA enrollees’ adequate access to care. GAO considered CMS’s definitions of “network adequacy” and the execution of criteria in light of other similar programs. Additionally, GAO examined the extent of CMS’s MAO network monitoring, the quality of beneficiaries’ termination communication, and other means of guidance regarding network adequacy, federal regulations, and internal control benchmarks.
GAO findings confirm that since 2011, CMS has defined an “adequate” MA provider as meeting two types of criteria: “a minimum number of providers and maximum travel time and distance to those providers.” Such requirements incorporate a variety of provider types and are specific to county types.
GAO confirms although other network-based health programs utilize provider availability measures to evaluate degrees of network adequacy, MA criteria “do not reflect aspects of provider availability, such as how often a provider practices at a given location.”
Says GAO, “Without taking availability into account, as is done in some other programs, MA provider networks may appear to CMS and beneficiaries as more robust than they actually are.”
GAO claims CMS’s network adequacy is not broadly applied. “CMS limits its annual application of the criteria to provider networks in counties that MA organizations (MAO) – private organizations that offer one or more health benefit plans – propose to enter in the upcoming year,” states GAO. “From 2013 through 2015, CMS's reviews accounted for less than 1 percent of all networks. To facilitate its review of these networks, CMS has established standardized data collection via an automated system. However, CMS does little to assess the accuracy of the network data in applications MAOs submit, even though the submissions contain the same data elements as in provider directories, which have been shown to be inaccurate in a number of government and private studies,” GAO maintains, additionally citing CMS’s lack of scrutiny and inconsistent MAO communications.
GAO maintains until CMS takes steps to verify MAO provider information, as outlined in federal internal control standards, the agency will lack confidence MAOs successfully meet network adequacy criteria.
