New or updated federal and state-level regulations require current, accu- rate, and complete online provider
directories for managed care organizations
(commercial and/or Medicare). As a result,
leadership in many managed care and related
organizations find themselves stuck within
one of the five stages of grief: denial,
anger, bargaining, depression, and
acceptance. The first four stages of
grief are all dead-ends rife with costly
unintended consequences to your
organization. Given the importance of
accurate provider directories in secur-
ing patient access to care, as well as
the steep financial penalties involved
in non-compliance, how can leader-
ship achieve acceptance and move forward?
First, let’s review the regulatory landscape.
Although the Centers for Medicare &
Medicaid Services (CMS) has always
required provider directories be accu-
rate and contain certain information,1
beginning in 2015, CMS noted that it had
“become aware of a range of issues with
online provider directories,” with recent
provider and beneficiary complaints
highlighting problems with accuracy
on some of the Medicare Advantage
Organization (MAO) provider directory
2 Subsequent Health Plan
Management System (HPMS) memos and
the Call Letters for Contract Years 2016
and 2017 detailed CMS’s intent to study
provider directory accuracy, to provide
additional guidance on its provider direc-
tory regulatory requirements, to initiate
a three-pronged approach to monitor
compliance with those regulations, and
to verify the accuracy of online provider
directories for plans offered by MAOs. The
most significant sign that CMS considers
provider directory accuracy to be a serious
issue is the relocation of provider directory
access guidance in the Medicare Managed
Care Manual from Chapter 3 – Marketing,
to Chapter 4 – Beneficiary Protections.
by Laura H. Peth, MPA, CFE
Provider directory accuracy:
Have you reached
» Federal and state-level managed care provider directory accuracy regulations and regulatory enforcement methods are changing.
» Current, accurate, and complete provider directory data is a must-have for managed care organizations at any point in time.
» It is tempting to deny the real impact of these new regulations or to bargain over implementation.
» To effectively adhere to these new requirements, leadership at managed care and related organizations must incorporate everyday
compliance into existing operations.
» When it comes to provider directory accuracy, connecting the dots, treating data integrity as the foundation of everything, and
strategic planning are necessary.
Laura H. Peth ( email@example.com) is Senior Manager - Health Care
Practice, Mazars USA LLP in Sacramento, CA. bit.ly/in-LauraPeth