Based on the CY24 Final Rule—the Centers for Medicare & Medicaid Services (CMS) is cracking down on Network Adequacy to improve access to Behavioral Health.
In order to build strong Medicare Advantage (MA) Behavioral Health networks that improve timely access to services—CMS is finalizing policies to strengthen network adequacy requirements and reaffirm MA organizations’ responsibilities to provide behavioral health services. Specifically, CMS will:
- Add Clinical Psychology and Licensed Clinical Social Work as specialty types subject to network standards, and make these types eligible for the 10-percentage point telehealth credit;
- Amend general access to services standards to include behavioral health services;
- Codify standards for appointment wait times for primary care and behavioral health services;
- Clarify that emergency behavioral health services must not be subject to prior authorization;
- Require that MA organizations notify enrollees when the enrollee’s behavioral health or primary care provider(s) are dropped midyear from networks;
- Require MA organizations to add behavioral health services as part of care coordination programs.
RISE Article—MA Plan Directories & Ghost Mental Health Networks
According to this recently published RISE article entitled MA plan directories haunted by ghost mental health networks, Senate Finance Committee study finds, by Ilene MacDonald, the lead-in states, “More than 80 percent of the identified listings for in-network mental health providers under Medicare Advantage (MA) plans were inaccurate or unavailable, according to a secret shopper study conducted ahead of a Senate Finance Committee hearing on ghost networks.”
The article went on to say “As part of the study, staff reviewed directories from 12 MA plans in six states, calling 10 systematically selected providers from each plan, for a total of 120 calls. Of the total 120 provider listings contacted by phone, 33 percent were inaccurate, non-working numbers, or unreturned calls. Staff could only make appointments 18 percent of the time.”
Previous studies also indicate this is an ongoing problem approaching nearly a decade.
What Should Plans Expect Now?
As a result of this final rule and a national focus on mental health, plans should expect CMS to increase its oversight efforts and hold them accountable for inaccurate data causing access to care issues.
We’re Here To Help—CODY’s team of industry experts has the expertise to help mitigate risk and ensure network data accuracy by:
- Assessing your current operations and providing recommendations
- Working with your team to implement effective processes and internal controls
- Identifying and mitigating high-risk areas
- Conducting one-time or ongoing provider directory reviews in CMS-targeted areas or across your whole network
ICYMI—here’s how to avoid significant & systemic issues with Online Provider Directories: Provider Directory Accuracy—Why is it Important?
To learn more, contact us today for a consultation.
About us: Founded in 2006, CODY® is an Industry leader in Governance, Risk, and Compliance (GRC) Solutions designed exclusively for health plans. We enable over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico to mitigate compliance risk, maximize efficiencies, and improve outcomes. Our Enterprise technology and innovative solutions reduce administrative costs, increase accuracy, ensure regulatory compliance, and provide a better experience for plan members and providers. www.codyconsulting.com