CMS Audit Finds Medicare Advantage Provider Directories Woefully Deficient

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EqualizeRCM Services‘ Partner, Heidi Henderson, 1st Assistant Credentialing Services, describes how CMS Audit finds Medicare Advantage Provider Directories woefully deficient.

 

Medicare Advantage provider directories are still packed with errors. That is the finding released last month based on federal audits of those directories. This audit was begun under the Obama administration and encompasses about one-third of Medicare Advantage plans every year. As reported by ModernHealthcare.com, the audit revealed that almost half of provider directory locations included at least one mistake.

 

Errors Included

  • The wrong location
  • The wrong phone number
  • That the provider was accepting new patients when they were not
For the third straight year, significant errors were found that may result in fines or other penalties for those insurers. The Centers for Medicare & Medicaid Services (CMS) may begin imposing monetary penalties. The Modern Healthcare report described CMS actions comprising 18 noncompliance notices; 15 warning letters; 7 warning letters with a request for a business plan. There have been no fines assessed as yet and the plans have 30 days to correct the identified compliance issues.

Based on the CMS investigation, there is a general lack of internal audit and directory testing in many Medicare Advantage organizations. CMS expects managed care plans to review their provider directories and correct inaccurate and missing information.

 

Survey Methodology

Auditors Called Providers’ Offices Directly to Verify this Information
  • Does the provider see patients at this location?
  • Does the provider accept the Medicare Advantage plan at this location?
  • Does the provider accept/not accept new Medicare Advantage patients?
  • What is the type of healthcare provider (i.e., PCP, oncologist)?
  • Are the practice name and provider’s name, address and telephone number correct?
How Provider Directory Errors Can Affect Consumer Choices
As an example of one type of error, a person may choose a Medicare Advantage plan because a long-time doctor is listed as being in the plan network. However, that information is incorrect and the individual must now choose a new doctor that may be in an inconvenient location.

Other errors include some providers who did not work at any of the directory locations, or who did not accept the health plan there. CMS auditors even found that, because the directory information had been out of date for a long time, some listed doctors had retired or even died.

You can read the full CMS Online Provider Directory Review Report here.

 

To learn more, please visit:

Heidi Henderson is Owner & President of 1st Assistant Credentialing Services. Heidi has over 25 years in the medical field performing billing, credentialing, and practice management responsibilities. Since 2008, Heidi has owned and operated her own consulting and credentialing business, giving her the opportunity to work with many different physicians in all areas of medicine. Because of her in depth knowledge of a medical practice, it was natural to start a business to assist physicians and administrators in managing day to day activities. Heidi understands that practice managers need assistance finding an honest credentialing company to help keep their practice up and running. 1st Assistant Credentialing Services is committed to excellence, honesty and fair pricing. 1st Assistant Credentialing Services is an independent consultant and credentialer since 2008, current member of MGMA and NAMSS, Texas MGMA and Capital City MGMA chapters.




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