Federal Authorities Find Physician Lists Often In Wrong Medicare Advantage Directories


The provider directories for private Medicare Advantage plans are riddled with errors, according to the government’s first comprehensive review.

The results released on Monday, arriving in the middle of the annual registration period until Dec. 7, validate long-standing criticisms of seniors and consumer advocates. The level of errors surprised regulators again, said officials from the Centers for Medicare & Medicaid Services who disclosed their findings at an industry conference in Washington.

Incorrect information was found for nearly half of the 5,832 physicians listed in the directories of the 54 Medicare Advantage plans audited last fall, they said. Only online directories were reviewed.

The government hopes a new rule this year will help raise that bar, as it requires Medicare Advantage plans to contact doctors and other providers every three months and update their online directories in “real time.”

CMS did not identify the names of the insurers that were interviewed.

CMS’s investigation found that the most error-prone lists involved physicians with multiple offices not serving health plan members in each location, said Christine Reinhard, health insurance specialist in the CMS division. monitoring, compliance and marketing.

The explanations could be that the doctor was retired, worked at a different location, or had never worked at the address. Or maybe the doctor never had a contract with the Medicare health plan – a less likely possibility, officials said.

The review also revealed:

  • Wrong phone numbers for 521 doctors’ offices.
  • Wrong addresses for 633 medical practices.
  • Error rates exceeding 60 percent of physicians surveyed for five Medicare Advantage plans.

CMS did not impose any fines but it could still happen, said Jeremy Willard, also a health insurance specialist in CMS’s surveillance division. Inaccuracies found in Medicare Advantage directories could result in penalties of up to $ 25,000 per day per beneficiary or re-listing and marketing bans.

Seniors rely on provider directories when choosing a health plan to identify network physicians. They also use them when looking for referrals to specialists.

“The errors compromise the recipient’s ability to be connected with a needed provider,” Willard said.

CMS conducted the investigation by randomly calling 108 physicians representing primary care, cardiology, ophthalmology and oncology for the Medicare Advantage companies. The highest error rates were among primary care physicians and cardiologists.

America’s Health Insurance Plans, the industry’s trade group, said its companies are working hard to make supplier directories accurate and keep them up to date.

“This is what consumers need – and this is what we are committed to improving,” said spokesman David Merritt, acknowledging the plans had to do better.

More than 17 million Americans, or nearly a third of Medicare beneficiaries, have coverage through Medicare Advantage plans.

Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals, and other health care providers that may change during the year.

CMS is also surveying Medicare Advantage companies this fall, and officials hope to survey all companies by 2018, when the triennial review is complete.

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Health industry Medicare

Benefits of CMS Health Insurance


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