On September 28, 2015, the Government Accountability Office (GAO) released a report regarding CMS controls of provider adequacy in Medicare Advantage Organization (MAO) networks.  The GAO pursued its review because many MAOs have been narrowing their provider networks, which has prompted concerns about enrollee access to care and CMS oversight of network adequacy requirements.  Among other recommendations, GAO recommended that CMS enhance oversight of MAO networks to improve provider availability, such as by requiring disclosure of how often a provider practices at a given location.

Specifically, the GAO reviewed how CMS ensures adequate access to care for Medicare Advantage patients, including an assessment of CMS’s network adequacy criteria, monitoring of MAO networks, and regulation of disclosures to beneficiaries about terminations of provider contracts.

Current MAO network criteria focus on the number of providers and travel time and distance to providers, but do not reflect provider availability. GAO recommended that CMS verify the accuracy of network provider data submitted by MAOs to ensure that MAOs meet network adequacy criteria. Further, the GAO recommended that CMS should conduct more reviews of established MAO provider networks to ensured continued compliance with adequacy standards. Finally, the GAO suggested that CMS set minimum information requirements to ensure that MAO communications regarding provider network terminations are clear, accurate, and consistent.

The GAO Report is available here.

Reporter, Lauren S. Gennett, Atlanta, + 1 404 572 3592, lgennett@kslaw.com.