Provider Directory Accuracy—Why is it Important?

Medicare Advantage Programs

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to post an online provider directory that is up-to-date and accurate. Beneficiaries must be able to use the online provider directory to find contracted providers they can see to receive covered services.

Inaccurate provider directories pose risks to beneficiaries.

Because members rely on provider directories to locate an in-network provider, inaccuracies could impede access to care, create barriers to services critical for their health and well-being, and impact a beneficiary’s ability to make informed healthcare choices. Furthermore, inaccurate provider data may question the adequacy and validity of your provider network and its compliance with CMS network adequacy requirements.

As a result, CMS implemented oversight activities to address issues with online provider directory data accuracy.

  • Between 2016 and 2018, CMS completed online provider directory reviews and indicated they plan to continue performing these reviews
  • Based on these reviews, CMS issued compliance actions to plans, including notices of non-compliance, warning letters, and warning letters with a request for business plans
  • CMS indicated they will consider enforcement actions for egregious instances of provider directory non-compliance

The CMS provider directory reviews revealed significant and systemic issues with health plan data. Most plans reviewed had between 30% and 60% of provider locations containing inaccurate data, and multiple plans had an error rate greater than 70%.

CMS identified several common drivers that may contribute to provider directory inaccuracies:

  • Group practices continue to provide data at the group level rather than at the provider level. Group practices often list a provider at a location because the group has an office there, even if that specific provider rarely or never sees patients at that location.
  • General lack of internal audit and testing of provider directory accuracy by health plans. It was documented that health plans did not create a validation process and instead relied on credentialing services, vendor support, and provider responses.
  • Providers themselves validated information via fax or email that was subsequently found to be incorrect when CMS directly called the office.

How to ensure these inaccuracies are caught and corrected before a CMS Audit?

  • Complete a comprehensive business process review to ensure that data points are pulling from the correct sources, processes to maintain and update provider data are effective, and validation and quality activities are targeting high-risk areas
  • Identify communication and outreach strategies with providers to reinforce contracting status and data integrity requirements
  • Establish internal mechanisms to identify and resolve potential issues
  • Implement regular monitoring and data validation activities to test your data and identify issues continuously

We help Medicare health plans mitigate risk and ensure provider data is accurate 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

CODY® has the team, expertise, and state-of-the-art technology to support health plan operations, improve performance, and ensure compliance with industry and regulatory standards. To learn more, contact us today for a consultation.

About CODY: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Membership Suite™, our proprietary suites of software, are designed specifically for health plans.