How to Prepare for a CMS Online Directory Audit


Friday, December 21, 2018

How to Prepare for a CMS Online Directory Audit

How to Prepare for a CMS Online Directory Audit

Dec 21, 2018

Author: Cheryl Cisneros, RN, CPCS, CPMSM, Manager, Client Success Services and Consulting


The Centers for Medicare and Medicaid Services (CMS) recently released the results of the Medicare Advantage Organization (MAO) online provider directory reviews. This is the third round of annual audits reviewing 5,602 providers at 10,504 locations.


The results of the audit found that overall, 48.74% of provider locations and had at least one deficiency. The importance of accurate provider directories is crucial to ensure a patient’s access to care.


Round One 45.10% Overall Inaccuracy

Round Two 55.07& Overall Inaccuracy

Round Three 48.74% Overall Inaccuracy


CMS’s goal is to drive industry improvement to provide accurate provider directories


Common provider types were selected as a focus for the three consecutive annual reviews. The provider types are Primary Care Physicians, Cardiologists, Oncologists, and Ophthalmologists. 50.14% of providers had at least one deficiency.


The top five Deficiency Types by Occurrence were reported:


    #1 Provider should not be listed in the directory at this location

    #2 Provider should not be listed at any of the directory-indicated locations

    #3 Phone Number needs to be updated (incorrect or disconnected)

    #4 Address needs to be updated

    #5 Address (suite number) needs to be updated


The findings suggest that Medicare Advantage Organizations are not adequately maintaining accurate directories.


CMS noted the following observations driving inaccurate provider directories:


  • Group practices continue to provide data at the group level than at the provider level.
  • A lack of internal review of directory by the MAOs.
  • Directory had been out of date for a long time – provider retired or deceased.

CMS issued compliance actions.


18 Non-Compliance Notices

15 Warning Letters

7 Warning Letters with a Request for Business Plan


What can you do to ensure successful outcomes and eliminate risk for CMS compliance actions?


Implement an internal audit process. CMS has provided the questions which they survey.


  1. Does the provider see patients at the location?
  2. Does the provider accept Medicare Advantage plan(s) at the location?
  3. Does the provider accept or not accept new patients who have a Medicare Advantage plan?
  4. Is the provider a PCP, cardiologist, oncologist, or ophthalmologist?
  5. Is the address correct?
  6. Is the telephone number correct?
  7. Is the provider name correct?
  8. Is the practice name correct?

Use this list in your internal reviews so you can answer “yes” when asked if your organization is ready for the next CMS Audit.

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