GAO Slams CMS' Oversight of Medicare Advantage Provider Networks

CMS must do more to ensure that Medicare Advantage plans have adequate networks, according to a Government Accountability Office report released Monday, Modern Healthcare reports.
The report was requested by: Sens. Richard Blumenthal (D-Conn.), Sherrod Brown (D-Ohio) and Sheldon Whitehouse (D-R.I.), as well as Reps.:

  • Joe Courtney (D-Conn.);
  • Rosa DeLauro (D-Conn.);
  • Elizabeth Esty (D-Conn.);
  • Jim Himes (D-Conn.); and
  • John Larson (D-Conn.).

Report Findings

GAO found several deficiencies in CMS’ oversight of MA plan network adequacy.
For example, the report found that CMS’ definition of an adequate network fails to account for:

  • How often providers practice at a specific location; or
  • Whether providers are accepting new patients (Dickson, Modern Healthcare, 9/28).

The report cited a 2014 study examining listings for about 4,700 dermatology providers in large MA plans. Of the listings, about 46% were duplicates and 8.5% of the individual providers had died, retired or moved (Young, CQ HealthBeat, 9/28).
GAO said, “Without taking availability into account, as is done in some other programs, MA provider networks may appear to CMS and beneficiaries as more robust than they actually are” (Modern Healthcare, 9/28).
According to GAO, CMS relies on reports from insurers about their networks and complaints from doctors who might have been blocked from MA plans to determine whether networks are adequate (CQ HealthBeat, 9/28).
However, the report found that CMS does little to assess the accuracy of network data submitted by plans in their applications.
GAO also found that CMS fails to detail what plans should do if they want to terminate provider agreements.

Lawmakers’ Reaction

Brown, who co-authored the Medicare Advantage Participant Bill of Rights (HR 4998), said MA beneficiaries “should be able to select a plan with an adequate provider network that meets all of their‎ needs and should have the security that their providers will not be dropped from the network in between enrollment periods” (Modern Healthcare, 9/28).
DeLauro plans to reintroduce a bill to allow MA plans to drop providers from networks because of medical negligence and violations of contractual requirements. She said that MA “patients have no recourse to stop bad behavior” by plans (CQ HealthBeat, 9/28).

CMS Response

CMS said it is taking steps to remedy issues brought up in the report. For instance, 2016 Medicare Advantage contracts will require provider directories to maintain better records of whether a provider is accepting new patients.
The agency is considering:

  • Developing a rule to bolster its network adequacy oversight; and
  • Requiring MA plans to submit the information they send to beneficiaries so the agency can ensure it is adequate (Modern Healthcare, 9/28).