ReduceYourRegulatoryRisk.pdf

Reduce Your Regulatory Risk

Overview of the Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans

CMS monitors network compliance by reviewing organizations’ networks on a triennial basis. They expect that organizations continuously monitor their networks for compliance with the current network adequacy requirements. The triennial network adequacy review cycle helps to ensure a consistent process for network oversight and monitoring. In addition, CMS may perform a network review after specific triggering events such as:

• Initial application
• Service area expansion (SAE) application
• Change of ownership transaction
• Network access complaint
• Significant Provider/facility contract termination
• Organization-disclosed network gap

RESULTS HAVE SHOWN

40% of plans fail to meet adequacy in more than 20% of counties
More than 50% of Medicare Advantage Plans have 30-60% inaccurate data
47% of recent CMS audits led to large financial penalties
CMS sees the inaccuracies of provider directories as posing a significant barrier to providing access-to-care.

What is the Cost of Inaccurate Data?

As a best practice when preparing for the Triennial Network Adequacy Review and year-round compliance monitoring, it’s imperative to keep in mind that network adequacy and network accuracy are inextricably linked. Compliance and Member satisfaction go hand in hand. Members need convenient access to the right number and types of providers and to find them differentiated within the provider directory. When considering the cost of inaccurate provider directory data for your organization, keep in mind enforcement and contract actions include: Civil Monetary Penalties (CMP), intermediate sanctions (i.e., suspension of marketing, enrollment, payment), and terminations. You will also want to consider the implications of inaccurate data on Member satisfaction, the impact of a decrease in your STAR Rating and HEDIS Score and accruing internal costs from processing member complaints.

Recommended Questions to Ask Your Teams

The last thing you want is to be surprised about the adequacy of your network when you submit for review.

• Are we confident that our directory is accurate and would pass the review today?
• What do we need to do immediately to be ready? Have we recently performed a mock audit?
• How do we ensure our data is current and in compliance with the Provider Directory policy?
• Do we perform routine validation checks on our provider data? What is our current process?
• Will our HSD table be accepted?
• What changes have been made to our provider network?
• How are we incorporating those changes into our data flow and directories?
• Can we pinpoint gaps in our network by county and by specialty?
• Do we know who to contract with to quickly and efficiently fill specialty gaps?
• Which teams and personnel need to be included in the pre-audit and ongoing process?
• Is everyone familiar with and/or understand the audit process?

You can’t manage what you can’t measure.
If you can’t measure it, you can’t improve it.

Best Practices to Maintain Adequate and Accurate Networks

Enterprise Tools to Measure, Manage and Monitor Network Performance

The most efficient plans have a provider network data management platform that is integrated into their workflow and is utilized across all teams and personnel, including Executives. Everyone has a lens to view and share the same data and details about the adequacy of the network in real-time. This approach enhances cross-team communication and alignment, provides the utmost transparency on the network, allows for quick decision making, reduces excess costs and ensures compliance of the network(s).

Validate Provider Data

• NPI - are there deactivated, invalid, missing or OIG Exclusion listed NPIs in your data?
  One way to minimize your risk and increase your member satisfaction is by maintaining accurate provider data. We recommend you have a continuous process of validating and auditing the information for each provider in your network. For example:

• Specialty – which providers are listed with multiple specialties?

• Number of Addresses – which providers are listed with multiple practicing locations?

Track and Trend Progress

Networks change continuously, often daily. It’s important to easily track the changes, have a plan for response to changes, and regularly monitor the trends of your network over time. This will help you be proactive in reporting the changes in your network(s) to regulators as well as understand if your network is headed in the right direction.

Utilize Gap Aging Analysis

It is critical that you have a way to be informed when a gap in your network(s) occurs, the length of time any gap has existed and a streamlined process to quickly fill the gap with the correct provider. This prevents surprises associated with maintaining adequacy.

Assess Provider Impact

To save your organization significant time, money and resources, have a tool that allows you to know the impact a provider has on the adequacy of your current network(s) and expansion opportunities before you contract with them. By understanding the value of each provider, you can easily identify the right providers to contract.