Medicare Advantage Networks

Starting in 2016  Medicare Advantage plans will be required to keep up-to-date online directories, or face large fines. The online directories allow the public (and insurance agents) to see which doctors are in a plan’s network and which ones are taking new patients.

According to an article in Kaiser Health News:

Under a rule published last month by the Centers for Medicare & Medicaid Services, Medicare Advantage plans must contact doctors and other providers every three months and update their online directories in “real time.”

Inaccuracies in the Medicare Advantage directories may trigger penalties of up to $25,000 a day per beneficiary or bans on new enrollment and marketing.

The new Medicare Advantage rules are a response to complaints from beneficiaries and doctors about “directories including providers who are no longer contracting with the [plan], have retired from practice, have moved locations, or are deceased,” CMS officials said in the notice to insurers. Some directories also list providers who are still in the plan’s network but not available to new patients.


This is certainly an issue with Medicare Advantage plans in Tucson.  I have seen doctors listed in plans’ online directories when I know they have retired or moved on.  I have also seen many primary care doctors listed as “accepting new patients” – but when I call the office I have been told they are not taking new patients.

So this new rule sounds like a good idea…. but requiring plans to contact every provider in their network every three months…..  that sounds like an expensive requirement.

3 comments for “Medicare Advantage Networks

  1. Reed
    03/30/2015 at 4:30 pm

    What process do the insurance co. use when they process a claim to see if a provider is in or out of network ? Apparently that list is kept up to date. The part about accepting new patients could be more of an issue. Perhaps the onus should be on the providers, by way of their network contracts, to keep the directories up to date.

  2. Denise
    04/02/2015 at 3:36 pm

    Doctor office staff always (usually?) check a person’s insurance even before the doctor sees the patient. I got a call today from a man who has Humana’s HMO Community plan which dropped it contract with University Physicians. He did not know this until he went to see his urologist and was told they were no longer in his network.

    Doctors want to get paid, so they their staff check insurance info before they deliver service (most of the time). A couple of years ago I had a client whose doctor sent him to LabCorp for blood test and the man ended up with a $300 bill because that lab was out-of-network for his HMO Medicare Advantage plan. The lab took his card and never told him they were not contracted with his plan!!! Bad front desk personnel.

    On line directories not being up to date is a problem for insurance agents/brokers who are trying to do right by their clients. We check the online directory and tell the client their doctor is “in-network” and then find out the doctor has moved on. Calling he doctor’s office is a good way to double check, but often the front desk staff do not know about who the docs are contracted with. It is all very complicated and getting more so each year.

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