WHAT YOU HEARD WE WERE DOING...

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1 Managed Care Compliance Conference February 15 18, 2015 WHAT DOES THE CHANGING LANDSCAPE OF PROVIDER NETWORKS MEAN FOR YOUR COMPLIANCE TOOLSHED? BEFORE AFTER WHAT YOU HEARD WE WERE DOING... 1

2 BEFORE AFTER WHAT WE WERE TRYING TO DO... 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 2

3 HEALTHCARE DELIVERY SYSTEM TRANSFORMATION Quality Cost Medical Associations and Other Stakeholders 3

4 News Media Coverage 4

5 OIG Report - Access to Care in Medicaid Managed 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 EXAMINING ACCESS TO CARE TAKES ON HEIGHTENED IMPORTANCE AS ENROLLMENT GROWS IN MEDICAID MANAGED CARE PROGRAMS. CMS MA Provider Network Guidance 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 CMS ANNOUNCED NEW AUDIT PROTOCOLS IT WILL PILOT IN CY 2015 AUDITS RELATED TO MA NETWORK ACCESS / ADEQUACY AND PROVIDER NETWORK DATA 5

6 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 6

7 NAIC revisions to Managed Care Plan 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 CMS STATED IT WILL REVISE ITS OWN NETWORK ADEQUACY STANDARDS FOR EXCHANGES BASED ON WHAT NAIC RECOMMENDS 7

8 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 TOOLS FOR YOUR TOOLSHED, AND HOW TO USE THEM PROVIDER NETWORK CHANGES / ACCESS & ADEQUACY Communication 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 OTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACY Frequent, proactive communication helps A LOT 8

9 OTHER BEST PRACTICES FOR NETWORK CHANGES / ACCESS & ADEQUACY What s what, who s who, where are they located, what do they do? 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) TOOLS FOR YOUR TOOLSHED, AND HOW TO USE THEM PROVIDER NETWORK DATA / DIRECTORY ACCURACY 9

10 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 Care CMS 2015 Call Letter, Part C Provider Contract Termination Guidance Medicare Managed Care Manual, Ch.4, Section 110 Access to and Availability of Services (includes Significant Changes to Networks ) CY2016 MA HSD Provider and Facility Specialties and Network Adequacy Criteria Guidance (issued by CMS annually) 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 Response 10