Medicare to Try Triennial Reviews of Doctor Networks

Is that psychiatrist accepting new beneficiaries? Didn’t that hospital close last year?       

Medicare beneficiary questions like these may be answered more accurately now that the Medicare agency will start reviewing private-plan managed care networks every three years.

The White House in late December okayed the Centers for Medicare & Medicaid Services’ (CMS) request to increase its reviews of Medicare Advantage organization (MAO) plan networks.  These are groups of physicians, hospitals, and others that have agreed to provide medical services to Medicare Advantage members at a discount.

CMS reviews networks against adequacy standards to ensure they consist of minimum numbers of providers, and travel times to those providers stay within limits. But that’s only done as part of the initial MA application process, or when there’s a trigger, like a complaint. 

A government watchdog took a look at CMS’s system a couple years ago and wasn’t satisfied by what it saw.

“For established provider networks, CMS does not require MAOs to routinely submit updated network information for review,” the Government Accountability Office said in a 2015 report. “But because a plan's providers may change at any time, CMS cannot be assured that networks continue to provide sufficient access for enrollees until the agency collects evidence of compliance on a regular basis,” the GAO advised. 

The every three-year cycle of reviews will start for MA plans offered in 2019.

“We've seen in our own work that some of the networks are very out of date,” Gretchen Jacobson, associate director of Kaiser Family Foundation's Program on Medicare Policy, told me. CMS has found many errors in provider directories so these reviews will hopefully improve that, she said.

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