CMS aims to clean up Medicare Advantage provider directories

A merger left Hannah Hale without options.

Digestive Health Associates of Dallas combined with Texas Digestive Disease Consultants in January 2021 to become GI Alliance, a specialty group that includes nearly 700 gastroenterologists in 14 states. GI Alliance and her health insurance company, Cigna, failed to reach Cignament. Bagut not update its provider directory.

To the Centers for Medicare and Medicaid Services, it appeared as though GI Alliance was in Cigna’s Medicare Advantage network and the insurer was in compliance with network adequacy requirements. In reality, Hale, 35, said she struggled for two years to find a gastroenterologist in her area willing to accept her cigna policy.

“I feel like a crazy, tin foil hat person because it seems like Cigna is intentionally doing things that are wrong,” Hale said. “Every patient in the Dallas area who sees a GI doctor who’s on my plan lost access to GI care. Their directory is just full of errors.”

Privacy laws prevent Cigna from discussing Hale’s specific experience, a company spokesperson wrote in an email. But the insurer meets all network adequacy standards in the Dallas area, the spokesperson wrote. “We regularly update our provider directories. … Occasionally be providers, Incorrectly, and we work to address these issues whenever they arise.”

CMS requires Medicare Advantage insurers to update provider directories quarterly. But Hale’s difficulties with Cigna illustrate the sad state of provider listings.

Nearly half, or 48.7%, of Medicare Advantage plan directories contained inaccuracies in 2018, according to the most recent federal review. Regulators have proposed rules to crack down on shadow listings and even pitched the creation of a national provider directory.

Instead of insurers loading providers’ contact information, availability and more into disparate systems, providers would sign into a centralized data hub to input their information, according to a proposal CMS made in October. Public and private payers would then use those data to assemble their own directories.

CMS cited a Council for Affordable Quality Healthcare study that projects transitioning directory data collection to a single platform could save physicians $1.1 billion in annual administrative costs. [national provider directory] could both streamline existing data across CMS systems and public information in an easier-to-use format than what is available today,” the agency wrote in its request for information.

The idea is disliked by nearly every party involved.

Not every health system operates the technology necessary to support the initiative, the American Hospital Association wrote to CMS last month. The hospital lobbying group expressed skepticism about the potential to lessen administrative burden and argued the initiative would overlap with reichreporting “ have, admittedly, been plagued with inaccuracies.” AHA asked CMS not to move forward with the plan.

“Adding an additional data source without sufficiently addressing how or why it differs from the myriad provider directories already in existence could further complicate patients’ ability to access accurate information,” the AHA wrote. “Meanwhile, such a requirement would add [a] Considerable, duplicative burden on providers.”

Insurers are concerned that the onus to constantly verify the accuracy of providers’ information would fall on them.

“It can’t be the federal government saying, ‘I’m going to push this responsibility down to health plans because I couldn’t figure out how to make a national directory that works.’ That doesn’t result in something that’s meaningful ,” said Michael Bagel, director of public policy at the Alliance for Community Health Plans, a trade group for nonprofit insurers.

CMS currently relies on insurers to regulate themselves when it comes to provider directories. The agency’s inability to hold companies such as Cigna accountable to its rules makes Hale skeptical about another new requirement by regulators.

Hale is enrolled in for disability benefits and strives full-time to manage her health. She suffers from multiple genetic and autoimmune disorders, including the gastrointestinal condition Crohn’s disease and Ehlers-Danlos syndrome, a connective tissue disorder. Treatments for these side effects such as short bowel syndrome, inflammatory arthritis and mast cell activation disorder, an immune disease, she said.

When Hale initially qualified for disability in 2016, she signed up for traditional Medicare for its wide network that would give her access to the variety of specialists she needs. But because Texas law prohibits people with disabilities from purchasing they are supplemental on the Medicare fee-for-service program left her with too many out-of-pocket expenses.

In 2017, Hale’s pharmacist recommended Medicare Advantage as a way to cap her out-of-pocket expenses, she said. Hale made a spreadsheet listing every doctor she visited and the insurance plans they accepted, then looked for policies with the most overlap. signed up for the Cigna Preferred Medicare PPO, which limited her to a network but would provide a degree of coverage for visits with out-of-network clinicians.

The first four years with Cigna were generally positive, Hale said. “Insurance is supposed to be hard, and they’re supposed to give you a hard time when you need things approved, and that just hadn’t been my experience with them, ” she said.

That changed in October 2021, when Hale’s long-time gastroenterologist at Digestive Health Associates refused to see her, writing in an email that, after the merger with GI Alliance, he could no longer treat Cigna members. She worried her complex condition would make It is difficult to find a replacement.

GI Alliance participates in-network for all major payers in the markets where it provides care, a spokesperson wrote in an email.

The notice from her gastroenterologist caught Hale by surprise. CMS requires Medicare Advantage carriers to notify patients—and update their online provider directories—within 30 days of network changes.

Hale said she had not heard a peep from Cigna. She checked Cigna’s provider catalog, which said every in-network gastroenterologist within 75 miles of Dallas was affiliated with GI Alliance service. When she called the insurer to complain, she talked to three customers represent , all of whom refused to believe that GI Alliance was out of network, she said.

“Their inability to see the situation for what it actually was versus what was on their computer screen was preventing me from accessing the GI care that my condition required,” Hale said. “I needed help, and the person said that she had no way To update the provider directory, she had no way to escalate this call, she had no way to do anything, and that we just needed to wait.”

Despite several more calls complaining to Cigna, the insurer still had not updated its listings by December, Hale said.

Hale decided to complain to CMS.

When patients file grievances about Medicare Advantage insurers to federal regulators, CMS records them in a tracking module and forwards the information to carriers with instructions for resolving the issues. Insurers generally have one month to rectify problems and have the discretion to declare irrelevant complaints on the own judgment. Because carriers’ bonuses through the star ratings quality program are partially contingent on how they respond to member complaints, insurers have a financial incentive to mark cases as closed.

Regulators can fine, freeze enrollment or enact other penalties against Medicare Advantage insurers that fail to comply with provider directory standards. CMS did none of those things in this case and never responded to Hale’s complaints after passing them on to Cigna. “They have never anything to enforce it,” Hale said.

CMS said it had nothing to enforce. Cigna is compliant with network adequacy standards for gastroenterologists in the Dallas area, a CMS spokesperson wrote in an email. The insurer provided Hale with in-network specialists and Hale agreed to contact a new provider for an appointment , according to the agency.

“CMS verified that the plan contacted the customer and provided names of physicians in the Dallas metropolitan area that were in network,” the spokesperson wrote.

CMS reviews Medicare Advantage plans networks every three years and has requested that its regional office review Cigna’s contract for the Dallas area this year. That request is pending, according to the agency.

The day after Hale contacted the Medicare agency, a Cigna representative called and explained the directory was out of date because the insurer had failed to update gastroenterologist’s credentials after the merger, which is why they were still improperly listed as in-network, the Cigna said, according to Hale.

Despite more written and telephone communications, that was the last bit of useful information Hale got from Cigna for months, prompting her to complain to CMS again in March 2022. Cigna responded the following month with the names of 13 in-network gastroenterologists not affiliated with The GI Alliance and subsequently removed most, but not all, of the providers from that practice from its directory.

Many of the physicians Cigna identified either weren’t accepting new patients or declined to see someone with needs as complex as Hale’s, she said. One only served Veterans Health Administration beneficiaries. Hale found a in-network gastroenterologist holocated nearby w medications but wouldn’t take her on as a long-term patient, she said.

Hale complained to federal regulators again in May and June about Cigna’s provider directory. That summer, Cigna mailed her two letters again saying they attempted to call her and asserted she had twice verbally agreed that the company had resolved her concerns that our problems. The appropriate protocol was followed in the handling of your complaint,” Cigna wrote in August 2022.

Medicare Advantage members may switch plans that change their networks at any time, not just during open enrollment. That wouldn’t have helped Hale because the insurer’s failure to notify CMS of changes to its network meant she had no documented reason to qualify for a enrollment. Hale also didn’t leave Cigna during open enrollment because she values ​​the out-of-network coverage the PPO offers. “It is really difficult to try to find one plan that covers my various specialists without losing access to them,” she said. said.