2/5/2015
Managed Care Compliance Conference
February 15–18, 2015
WHAT DOES THE CHANGING LANDSCAPE OF
PROVIDER NETWORKS MEAN FOR YOUR
COMPLIANCE TOOLSHED?
BEFORE
AFTER
WHAT YOU HEARD WE WERE DOING . . .
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2/5/2015
BEFORE
AFTER
WHAT WE WERE TRYING TO DO . . .
TOPICS WE WILL COVER
Why care provider networks are changing
Media, regulator and other stakeholder
reactions to provider network changes
Business and compliance strategies and tools
to help manage this evolving risk area
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2/5/2015
HEALTHCARE DELIVERY SYSTEM TRANSFORMATION
Quality
Cost
Medical Associations
and Other Stakeholders
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2/5/2015
News Media Coverage
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2/5/2015
OIG Report - Access to Care in Medicaid
Managed Care Plans
•
•
•
Medicaid health plan provider network
directory accuracy
Availability of provider appointments
51% of plan providers contacted
were not able to offer appointments
•not
available at the location listed
•not accepting new Medicaid patients
•not participating in the plan
“EXAMINING ACCESS TO CARE TAKES ON HEIGHTENED IMPORTANCE AS
ENROLLMENT GROWS IN MEDICAID MANAGED CARE PROGRAMS.”
PROGRAMS.”
CMS MA Provider Network
Guidance and Standards
•
•
•
CY2015 Call Letter
Provider Contract
Termination Guidelines
MMCM, Ch.4, Provider
Network Standards,
Significant Changes to
Networks
MA Health Services
Delivery (HSD) Criteria
CMS ANNOUNCED NEW AUDIT PROTOCOLS IT WILL PILOT IN CY 2015 AUDITS
AUDITS
RELATED TO MA NETWORK ACCESS / ADEQUACY AND PROVIDER NETWORK DATA
DATA
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2/5/2015
KEY CHANGES IN CMS GUIDANCE
Requirement to notify CMS 90 days in advance of
‘significant’ plan-initiated network changes
Explain how access, notice and continuity of care
requirements will be met
Special Election Period (SEP)
Existing SEP for exceptional circumstances
Plan-initiated, mid-year, ‘significant’ changes
Enrollee must demonstrate they’ve been affected
SEPs will not be granted for changes effective 1/1 if
enrollees notified prior to Annual Enrollment Period
KEY CHANGES IN CMS GUIDANCE
Recommendation (best practice) to give affected
providers more than 60 days advance notice
Recommendation to give affected enrollees more
than 30 days advance notice
Recommendations for enrollee notice content
Contact information for alternative providers in network
How to request continuity of care exception
How to contact customer service for assistance
Recommendations for call center talking points
and FAQs for responding to inquiries from
enrollees, provider and other stakeholders
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2/5/2015
NAIC revisions to Managed Care Plan
Network Adequacy Model Act (#74)
Proposed new requirements include
•
submit “access plans” to state
regulators (filing or approval)
•
access / adequacy criteria
•
provider directory requirements
•
continuity of care requirements
CMS STATED IT WILL REVISE ITS OWN NETWORK ADEQUACY STANDARDS FOR
EXCHANGES BASED ON WHAT NAIC RECOMMENDS
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2/5/2015
•
Prevention:
•
•
•
•
Detection:
•
•
•
•
Compassion
Communication
Coordination
Increase frequency / scope
of network monitoring
Monitor member and
provider calls, complaints
and appeals
Listen to other stakeholders
Correction
•
•
Rapid response
Feedback loops
TOOLS FOR YOUR TOOLSHED, AND HOW TO USE THEM
PROVIDER NETWORK CHANGES / ACCESS & ADEQUACY
Communication Plan
Consider not just providers, enrollees but
also those groups that advocate for them
• Medical Associations / Societies
• State Health Insurance Assistance
Programs (SHIP) offices
Consider not just your primary regulator
(CMS / Medicaid Agency) but also others
that may receive complaints / inquiries
• State Departments of Health
• State Departments of Insurance
• State Attorney General
Be ready with a media response plan
OTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACY
Frequent, proactive communication helps – A LOT
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2/5/2015
OTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACY
What’s what, who’s who, where are they located, what do they do?
•
Prevention:
•
•
•
Detection:
•
•
•
Educate providers on
importance of updating data
Simplify provider update
process (e.g., portals, CAQH)
Contact providers for updates
if many office locations listed,
multiple specialties listed, no
recent claims history, recent
acquisition, etc.
Compare plan network data to
other sources of data (CAQH,
Medicare, USPS, etc.)
Correction
•
•
Rapid response
Education / feedback loop with
providers (importance of
updating data)
TOOLS FOR YOUR TOOLSHED, AND HOW TO USE THEM
PROVIDER NETWORK DATA / DIRECTORY ACCURACY
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2/5/2015
WHAT ELSE? OTHER QUESTIONS?
We covered
Why managed care provider networks
are changing
What we can learn from media,
regulator and other stakeholder
reactions to these changes
How you can use business and
compliance strategies / tools to help
manage this evolving risk area
Focused on network access &
adequacy, provider directory data
accuracy
REFERENCE MATERIALS / RESOURCES
OIG Report: Access to Care – Provider Availability in Medicaid Managed Care
http://oig.hhs.gov/oei/reports/oei-02-13-00670.asp
CMS 2015 Call Letter, Part C Provider Contract Termination Guidance
http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/downloads/Announcement2015.pdf
Medicare Managed Care Manual, Ch.4, Section 110 – Access to and
Availability of Services (includes ‘Significant Changes to Networks’)
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf
CY2016 MA HSD Provider and Facility Specialties and Network Adequacy
Criteria Guidance (issued by CMS annually)
http://www.cms.gov/Medicare/MedicareAdvantage/MedicareAdvantageApps/Downloads/CY2016_MA_HSD_Network_Criteria_Guidance.pdf
National Association of Insurance Commissioners (NAIC) – Draft Revisions
to Network Adequacy Model Act, Comments in Response
http://www.naic.org/committees_b_rftf_namr_sg.htm
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