For years, Medicare Advantage plans have listed physicians and hospitals in their network directories who were not in fact in-network. They misled enrollees about their provider networks. The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, is proposing reforms that could help ensure that Medicare Advantage plans do not mislead enrollees about their provider networks, reports Dave Muoio for Fierce Healthcare.
CMS has proposed a rule that requires Medicare Advantage plans to update their provider directories every three months. If finalized, CMS would give each Medicare Advantage plan a network accuracy score beginning in 2029. People with Medicare could choose a Medicare Advantage plan based on its network accuracy score if they wanted to.
The accuracy score does not indicate whether enrollees will be able to see the providers they need to see, nor can it reflect the reality that providers can leave Medicare Advantage networks at any time during the year or simply stop taking new patients. And, people enroll in Medicare Advantage often without knowing what condition they will develop or what providers they will want to see.
The proposed rule does not go far enough. CMS should be penalizing Medicare Advantage plans with inadequate networks. Simply raising awareness that their directories are misleading does not do enough to ensure that insurers are complying with network adequacy requirements. It still could leave patients with cancer, heart disease and other costly conditions without access to providers that can best treat their conditions.
CMS does propose requiring Medicare Advantage plans to charge the same cost-sharing to enrollees as they would pay in-network if the network directory suggests a provider is in-network even if the provider is not in-network. If finalized, this proposal could at least keep Medicare Advantage plans from misleading enrollees about their provider networks.
Of course, the real issue for enrollees is whether their Medicare Advantage plans will cover the care they need. Too often, Medicare Advantage plans require enrollees to go through a prior authorization process. They then can and do often delay and inappropriately deny the care their enrollees’ treating physicians recommend. Neither CMS nor Congress has yet addressed this serious issue.
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