The Centers for Medicare & Medicaid Services (CMS) turned things up a notch with new provider directory requirements last year, and now they’re doubling down with Corrective Action Plan requests for Medicare Advantage (MA) Organizations that aren’t playing by the rules. We’re breaking down the latest news about the added provider directory requirements and Corrective Action Plan requests.
How Does CMS Monitor Medicare Advantage Organizations?
CMS monitors MA organizations throughout the year to ensure they comply with program requirements. They accomplish this through comprehensive monitoring activities that cover both operational and financial aspects. As part of this process, CMS periodically reviews the online provider directories to evaluate provider data accuracy. These reviews take place outside of the regular audit timeframe. When data discrepancies or inaccuracies are found, CMS will request a Corrective Action Plan from the MA organization.
What is a Corrective Action Plan?
According to the statute, Corrective action plans are requested for particularly serious or continued noncompliance with the requirements of the MA organization’s current or prior Part C contract with CMS.
CMS issues a corrective action plan if CMS determines that the MA organization has repeated or not corrected noncompliance identified in prior compliance actions, has substantially impacted beneficiaries or the program with its noncompliance, or must implement a detailed plan to correct the underlying causes of the non-compliance.
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What are the Provider Directory Trends in Recent Corrective Action Plan Requests?
In addition to current provider directory requirements, CMS introduced new requirements for provider directories, leading to MA organizations receiving Corrective Action Plan requests for failure to maintain accurate directories.
1. Provider Data Elements Must Be Verified and Accurately Listed in the Provider Directories
MA organizations must include Cultural and Linguistic Capabilities, including American Sign Language, for each provider in their directories.
2. Provider Directories Must Be Searchable by Every Provider Data Element
MA organizations must make their provider directories searchable by every provider data element required in the model provider directory.
What Are Medicare Advantage Organizations Required to Do When They Receive a Corrective Action Plan Request?
When an MA organization receives a Corrective Action Plan request from CMS due to inaccurate provider directory listings, it has limited time—typically 30 days—to address the issues. The MA organization must take the following actions.
1. Correct the Provider Directory Information
Correct any inaccurate listings in the provider directory.
2. Work with Providers
Collaborate with providers who must correct and update the required data elements.
3. Create a Detailed Corrective Action Plan
Have a detailed plan that shows the steps the MA organization will take to improve provider directory accuracy and the actions the organization will take to prevent inaccuracies from recurring.
Pro Tip: Showcase Compliance Efforts with Provider Outreach Metrics
Keep detailed records and provider outreach metrics easily available to demonstrate your provider data accuracy efforts to CMS.
Will CMS Compliance Oversight Continue to Focus on Provider Directory Accuracy?
Yes. CMS’s compliance monitoring of MA organization provider directories will continue to be a key focus. MA organizations will want to align their processes with the requirements and have the data insights to explain their position to CMS if needed. The increase in oversight is to promote transparency and help consumers have trust in the insurance plan they purchased.
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How Can Medicare Advantage Organizations Avoid Receiving a Corrective Action Plan Request?
To avoid receiving a Corrective Action Plan in your inbox, here are a few key items to remember.
- Evaluate Your Process and Solutions: Double-check that your current provider outreach, verification, and data management efforts are keeping you compliant.
- Include Extra Provider Data Elements: Don’t forget to verify specialty and cultural and linguistic capabilities.
- Make the Provider Directories Searchable: Ensure beneficiaries can search by all required elements, including cultural and linguistic capabilities.
CMS’s increased scrutiny of provider directories underscores the importance of maintaining provider data accuracy. Corrective Action Plan requests will continue to be a focus. By staying informed about the requirements, implementing necessary changes, and working with Quest Analytics, MAOs can maintain compliant and trustworthy provider directories.
Interested in keeping your directories up to standard and avoiding compliance issues? Schedule a time to connect with one of our experts.
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