MA Provider Directories and CMS Marketing Guidelines: Did Plans Get Off Easy?

By James Gutman - July 21, 2015

Provider directories, not long ago an annual hard-copy document customarily banished shortly after receipt to either the “circular file” or the nethermost reaches of beneficiaries’ storage areas, are now one of the hottest areas for regulations in Medicare Advantage (MA). If there had been any doubt about that, it probably was erased in the revised Medicare Marketing Guidelines CMS released this month.

The problem in a nutshell is that beneficiaries understandably want provider directories to be current. The members complain about insufficient access if they contact a provider listed in either a hard-copy or online directory and find that he or she either no longer is in the MA plan’s network or won’t accept new patients. And many plans contend, as Gorman Health Group, LLC President and CEO Jeff Fox notes, that they sometimes are “the last to know” when a network provider decides to stop taking new MA patients. Of course, often plan sponsors bring some of the problems on themselves when they unintentionally disseminate erroneous information in directories, as Aetna Inc. did on pharmacies in the Annual Election Period (AEP) for 2015, or shrink networks in midyear, or fail to try to verify the information on a regular basis.

CMS’s actions in the new marketing guidelines to deal with this were foreshadowed in the 2016 final MA payment notice issued in April and are actually quite restrained, some industry consultants concede, but they will mean big changes for many MA operators. The agency is not requiring the sponsors to keep mailing revised hard-copy provider directories to all members, but instead simply is telling plans they must make it easy for beneficiaries to request and be promptly sent (i.e., within three business days) such directories.

Sponsors will, though, have to “create a special mailing” when there is a “significant change” to the network, and in all cases update the online versions of the directories in real time or at least very quickly. They’ll also have to use “a special notation” in the online directory to highlight providers not accepting new MA patients, according to CMS. And in any marketing meeting the MA plans hold in future AEPs, CMS says in the guidelines, sales representatives need to bring technology sufficient to show Medicare beneficiaries how to access current provider information online.

What do you think about this problem and the proposed solution? Given the nonstop nature of provider-network changes, will it be sufficient to convey current information at least the vast majority of the time? Should plans be thankful that CMS didn’t come down harder on furnishing frequently revised hard-copy directories? How can plans do a better job of keeping their directories up to date before CMS indeed does crack the whip harder?

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