8 Data Tips for Medicare Advantage Network Adequacy Reviews

Your Medicare Advantage provider network is a strategic cornerstone of your organization’s success—but its true value hinges on the accuracy, reliability, and integrity of its provider data. Whether you’re reviewing your network data for a Medicare Advantage Application, preparing for a Triennial Network Adequacy Review, or simply want to make sure you’re addressing regulatory requirements throughout the year, following best practices is essential.

To help you stay compliant and achieve better results, we’re sharing eight strategies that can set your network up for success.

New Era of CMS Compliance

Increased Focus on Provider Data Accuracy and Network Adequacy Requirements

Medicare Advantage Organizations (MAOs) are no strangers to network adequacy and provider directory accuracy requirements. As policies change, the frequency and depth of data audits have increased. For instance, the Triennial Network Adequacy Review extends beyond the conventional 3-year triennial network adequacy review. Initial or service area expansion contracts may be subject to an audit in their first year of operation.

Another example is CMS Corrective Action Plans, which have shown a keen eye on the adherence to new provider data rules introduced last year. This move underlines just how crucial compliance is. It’s a clear testament to the CMS’s efforts to ensure that MAOs truly live up to these compliance standards.

How to Prepare Your CMS HSD Table For An Audit

Remove Excessive Provider Locations

You’ve heard it before: Location, location, location! But we’re not talking about houses, we’re talking about the provider addresses listed in your HSD Tables, and what you can do to prepare for your next CMS audit.

Paula Partin, our Senior Director of QES Adequacy, shares the answer to one of the hottest questions on the minds of many Medicare Advantage Organizations: Does CMS allow certain specialties to be listed at more locations than others?

She also reminds you that to be ready for an audit, you need to know which providers are listed in your data at an excessive number of locations—and you need to know sooner rather than later. By doing so, you give yourself more time to make any necessary changes to your data or provider network.

8 Data Management Tips For Compliant HSD Tables

Moving from triennial to annual audits places significantly more responsibility on MAOs to continually monitor provider data and proactively rectify discrepancies before the CMS intervenes. Changes in provider information, contract alterations, and specialty gaps can draw the attention of not only regulators but also members. Here are eight tips for ensuring that data in HSD tables is accurate, compliant, and well-prepared for audits.

Strategic data management plays a paramount role in preparing for audits and maintaining network adequacy. Here are eight invaluable tips to ensure the compliance and integrity of your HSD Tables:

1. Synchronize Provider Directories and HSD Tables

Ensure that your provider directories are always aligned with your HSD Tables. It’s crucial to regularly compare and correct the data to maintain both accuracy and compliance with CMS regulations.

2. Verify Address Consistency

Before submitting your HSD Tables, cross-verify the addresses with those in your provider directories. Any discrepancies, particularly incorrect NPI and location pairings, must be corrected to ensure data integrity.

3. Limit Provider Listings to 10

Consider setting a cap on the number of locations at which each provider is listed, ideally between 5 to 10. This practice is in response to CMS’s scrutiny of providers with excessive listings, although specific guidelines may vary.

4. Include Only Viable Locations

In your HSD Tables, list only those provider locations where members can feasibly schedule appointments. Providers who serve as substitutes or are not permanently stationed at a location should not be included.

5. Confirm Facility Specialty Locations

Verify and list only those facilities that are present and accessible to individuals within your service area, ensuring that your data matches the actual services offered.

6. Distinguish Between Individual and Organizational NPIs

Reflect accurate provider information by listing only individual National Provider Identifiers (NPIs) on your HSD Tables, not organizational NPIs.

7. Ensure NPI Validity and Compliance

All NPIs listed must be valid, recently attested, and checked against the Office of Inspector General (OIG) exclusions database.

8. Evaluate Network Post Adjustments

Following the removal of providers with unwarranted multiple locations, reassess your network for any potential service gaps. Promptly address these gaps to maintain network adequacy and adhere to CMS expectations for accurate HSD Tables.

Building Trust with Quality Data Audits

Regular provider data audits are a chance to ensure that your network consistently meets and even surpasses expectations. By detecting changes early, you can make the necessary adjustments to improve the quality of the network, remove irrelevant providers, and update your directory. When you take these steps, you have a better chance to win the hearts of your members and build their confidence in your insurance plan-leading to higher retention rates and more success for you.