Formal Network Review
Formal Network Review: Initial applications and SAEs are reviewed by CMS starting in June of each year. Retium Health brings the expertise needed to support plans analyze their networks before submission and help identify potential non-compliant areas.
As network issues emerge, Retium Health will review the CMS Automated Criteria Check (ACC) report as well as the HSD Zip Code report to identify where the plan does not provide adequate access to beneficiaries. We will work with clients to remediate any problems and develop targeted solutions which may include mapping to identify additional providers or develop the necessary exception requests. Our team will also review and validate CMS’s supply file for each affected county to not only recognize additional providers in the area but also thoroughly review the file to identify errors including providers that are inaccurately included in this file (incorrect office location or included in wrong specialty type). The team will also provide alternative providers to cover those areas. We also support organizations as they interact with CMS during the review process.
Triennial Reviews: Retium Health will also prepare organizations for triennial reviews. We will work with your team to assess potential areas where your plan is not meeting MA network adequacy criteria. Proactively addressing network challenges is key since CMS provides limited time (60-day advanced notice) to remediate issues. We will help your team identify areas where your network is not compliant, pinpoint key providers that may resolve deficiencies, develop appropriate ERs as appropriate and validate providers in the CMS provider supply file. This will help your organization reduce risks and avoid costly compliance actions.
CMS Consultation Process: CMS also offers a voluntary consultation process under which organizations applying for an initial application or SAE may submit their networks through their HSD table along with any anticipated exception requests for an initial, non-binding review. This is a great opportunity to present your organization’s case to CMS (challenges meeting criteria, errors in the supply file, etc) and be better prepared for the formal review process. Retium Health can help your organization with this process including interacting with CMS to understand any concerns and present your case.
Provider Directories Continue to be a Challenge
A recent CMS review identified that the majority of MAOs had between 30 and 60% inaccurate provider locations. Retium Health analyzed the CMS supply file and for example, we reviewed a group of PCPs in a county and identified that approximately 60% of these providers had either an incorrect office location or were not providing services in the specialty type assigned which could affect the ability to meet criteria in a county. Our team identified alternative providers in nearby locations that could potentially cover those deficient zip codes.