2/5/2015

1

WHAT DOES THE CHANGING LANDSCAPE OF

PROVIDER NETWORKS MEAN FOR YOUR

COMPLIANCE TOOLSHED?

Managed Care Compliance Conference

February 15–18, 2015

WHAT YOU HEARD WE WERE DOING . . .

BEFORE AFTER

2/5/2015

2

WHAT WE WERE TRYING TO DO . . .

BEFORE AFTER

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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3

HEALTHCARE DELIVERY SYSTEM TRANSFORMATION

Quality

Cost

Medical Associations Medical Associations Medical Associations Medical Associations

and Other Stakeholdersand Other Stakeholdersand Other Stakeholdersand Other Stakeholders

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News Media CoverageNews Media CoverageNews Media CoverageNews Media Coverage

2/5/2015

5

“EXAMINING ACCESS TO CARE TAKES ON HEIGHTENED IMPORTANCE AS “EXAMINING ACCESS TO CARE TAKES ON HEIGHTENED IMPORTANCE AS “EXAMINING ACCESS TO CARE TAKES ON HEIGHTENED IMPORTANCE AS “EXAMINING ACCESS TO CARE TAKES ON HEIGHTENED IMPORTANCE AS

ENROLLMENT GROWS IN MEDICAID MANAGED CARE PROGRAMSENROLLMENT GROWS IN MEDICAID MANAGED CARE PROGRAMSENROLLMENT GROWS IN MEDICAID MANAGED CARE PROGRAMSENROLLMENT GROWS IN MEDICAID MANAGED CARE PROGRAMS.”.”.”.”

OIG Report OIG Report OIG Report OIG Report ---- Access to Care in Medicaid Access to Care in Medicaid Access to Care in Medicaid Access to Care in Medicaid

Managed Care PlansManaged Care PlansManaged Care PlansManaged 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

CMS ANNOUNCED NEW AUDIT PROTOCOLS IT WILL PILOT IN CY 2015 AUDITCMS ANNOUNCED NEW AUDIT PROTOCOLS IT WILL PILOT IN CY 2015 AUDITCMS ANNOUNCED NEW AUDIT PROTOCOLS IT WILL PILOT IN CY 2015 AUDITCMS ANNOUNCED NEW AUDIT PROTOCOLS IT WILL PILOT IN CY 2015 AUDITS S S S

RELATED TO MA NETWORK ACCESS / ADEQUACY AND PROVIDER NETWORK DATRELATED TO MA NETWORK ACCESS / ADEQUACY AND PROVIDER NETWORK DATRELATED TO MA NETWORK ACCESS / ADEQUACY AND PROVIDER NETWORK DATRELATED TO MA NETWORK ACCESS / ADEQUACY AND PROVIDER NETWORK DATAAAA

CMS MA Provider Network CMS MA Provider Network CMS MA Provider Network CMS MA Provider Network

Guidance and StandardsGuidance and StandardsGuidance and StandardsGuidance 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

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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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CMS CMS CMS CMS STATED STATED STATED STATED IT WILL REVISE ITS OWN NETWORK ADEQUACY IT WILL REVISE ITS OWN NETWORK ADEQUACY IT WILL REVISE ITS OWN NETWORK ADEQUACY IT WILL REVISE ITS OWN NETWORK ADEQUACY STANDARDS FOR STANDARDS FOR STANDARDS FOR STANDARDS FOR

EXCHANGES BASED EXCHANGES BASED EXCHANGES BASED EXCHANGES BASED ON WHAT ON WHAT ON WHAT ON WHAT NAIC RECOMMENDSNAIC RECOMMENDSNAIC RECOMMENDSNAIC RECOMMENDS

NAIC revisions to Managed Care Plan NAIC revisions to Managed Care Plan NAIC revisions to Managed Care Plan NAIC revisions to Managed Care Plan

Network Adequacy Model Act (#74)Network Adequacy Model Act (#74)Network Adequacy Model Act (#74)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

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TOOLS FOR YOUR TOOLSHED, AND HOW TO USE THEM

PROVIDER NETWORK PROVIDER NETWORK PROVIDER NETWORK PROVIDER NETWORK CHANGES / ACCESS & ADEQUACYCHANGES / ACCESS & ADEQUACYCHANGES / ACCESS & ADEQUACYCHANGES / ACCESS & ADEQUACY

• Prevention:

• Compassion

• Communication

• Coordination

• Detection:

• Increase frequency / scope

of network monitoring

• Monitor member and

provider calls, complaints

and appeals

• Listen to other stakeholders

• Correction

• Rapid response

• Feedback loops

Frequent, proactive communication helps – A LOT

OTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACYOTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACYOTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACYOTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACY

Communication PlanCommunication PlanCommunication PlanCommunication 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

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OTHER BEST OTHER BEST OTHER BEST OTHER BEST PRACTICES PRACTICES PRACTICES PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACYFOR NETWORK CHANGES / ACCESS & ADEQUACYFOR NETWORK CHANGES / ACCESS & ADEQUACYFOR NETWORK CHANGES / ACCESS & ADEQUACY

What’s what, who’s who, where are they located, what do they do?

TOOLS FOR YOUR TOOLSHED, AND HOW TO USE THEM

PROVIDER NETWORK DATA / DIRECTORY ACCURACYPROVIDER NETWORK DATA / DIRECTORY ACCURACYPROVIDER NETWORK DATA / DIRECTORY ACCURACYPROVIDER NETWORK DATA / DIRECTORY ACCURACY

• Prevention:• Educate providers on

importance of updating data

• Simplify provider update process (e.g., portals, CAQH)

• Detection:• 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)

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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 Carehttp://oig.hhs.gov/oei/reports/oei-02-13-00670.asp

� CMS 2015 Call Letter, Part C Provider Contract Termination Guidancehttp://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/Medicare-

Advantage/MedicareAdvantageApps/Downloads/CY2016_MA_HSD_Network_Criteria_Guidance.pdf

� National Association of Insurance Commissioners (NAIC) – Draft Revisions

to Network Adequacy Model Act, Comments in Responsehttp://www.naic.org/committees_b_rftf_namr_sg.htm