AIS Newsletter Offers Coverage, Analysis of New CMS Strategy on Monitoring MA Provider Access

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CMS’s new, more robust version of its Network Management Module highlights the agency’s attention to provider access, reports Atlantic Information Services’ Medicare Advantage News.

With the launch of the Centers for Medicare & Medicaid Services’ (CMS) more robust Network Management Module (NMM) tool, monitoring provider-network adequacy will take a technological leap foward. The May 21 issue of Atlantic Information Services, Inc.’s (AIS) Medicare Advantage News (MAN) offers in-depth coverage of the new NMM tool, as well as analysis from industry experts on why CMS is moving in this direction.

The changes coming to the NMM were announced at CMS’s recently held annual spring Medicare Advantage (MA) and Part D conference and webinar. Initial use of the NMM will be in a pilot program starting late summer, with more details coming at CMS’s June 16 audit compliance conference.

MA provider access has become a major issue for CMS, following moves by several leading insurers to shrink the size of their networks in order to maximize clinical and financial outcomes, MAN reports. The new NMM will put pressure on plans to make sure their members have convenient access to providers, especially specialists. The revamped tool will allow for more frequent checks of the provider-network locations supplied by plans and compare those with where beneficiaries reside, explained Gregory Buglio, a health insurance specialist in CMS’s Medicare Drug Benefit and C & D Data Group, at the conference.

“CMS wants to be sure that when you say [to plan members] your providers are in network, they really are,” Shelley Mueller, director, government programs practice at consulting firm HTMS, tells MAN. Michael Adelberg, senior director at FaegreBD Consulting and a former top MA plan regulator at CMS, agrees, adding that “the tool will let CMS measure provider networks 365 days a year. MA plans will have to stay focused on keeping their networks as strong as they were when first approved.”

NMM gives the agency the ability to respond to complaints about networks without expending more resources than it has available for midyear checks, said a source who asked not to be identified. So when CMS gets a midyear complaint in the future about an MA plan’s network, it will be able to ask the insurer involved for provider-network evaluation through the NMM, and can impose sanctions if the access as determined by the NMM is inadequate.

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About Medicare Advantage News
Medicare Advantage News is the health care industry’s #1 source of timely news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in this hotly contested area of health insurance. Published biweekly since 1994 (when it was Medicare+Choice), the newsletter exists to help plans boost revenues, increase enrollees, cut costs and improve outcomes in Medicare Advantage and Medicaid managed care. Visit for more information.

About AIS    
Atlantic Information Services, Inc. (AIS) is a publishing and information company that has been serving the health care industry for more than 25 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, websites, looseleafs, books, strategic reports, databases, webinars and conferences. Learn more at

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Jill Brown, Executive Editor
Atlantic Information Services
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