Why Network Adequacy
CMS requires that organizations contract with a sufficient number of providers and facilities to ensure that at least 90 percent of enrollees within a county can access care within specific travel time and distance requirements (CMS, Medicare Advantage and Section 1876 Cost Plan Network Adequacy Guidance).
Developing networks that meet CMS network adequacy criteria is essential for plans entering new markets or expanding service areas within a contract and avoiding CMS compliance actions while ensuring adequate access for beneficiaries. In addition, CMS has instituted a triennial review process to ensure that existing plans maintain networks that meet the required standards. Failure to meet CMS network requirements may have significant consequences leading to compliance actions that may include suppression from Medicare’s Plan Finder or imposing that organizations allow enrollees to seek out-of-network providers/facilities at in-network cost-sharing.
Retium Health brings the necessary expertise to support your organization develop compliant networks and mitigate risks for health plans.
Provider Network Adequacy – a critical component of your plan’s success
Failure to meet Medicare Advantage network requirements may lead to compliance actions by CMS. These actions can have significant economic implications and detract from your organization’s success in one of the most attractive markets for healthcare plans.