WASHINGTON, D.C. – A Government Accountability Office (GAO) report released today shows that the Centers for Medicare & Medicaid Services (CMS) need to take action to ensure Medicare Advantage (MA) participants can access an appropriate number of doctors, known as an adequate provider network. CMS defines an adequate provider network has having a minimum number of providers, and a certain travel time and distance to those providers.

GAO had several findings, namely that this criteria should be broadened, namely by taking provider availability into account. Other federal health programs, such as Medicaid and TRICARE already take this action. GAO also found that CMS has done nothing to verify the information of providers before it goes to patients and much of it has been outdated or inaccurate.

The report can be read in its entirety here. It was requested by U.S. Sens. Sherrod Brown (D-OH), Richard Blumenthal (D-CT), and Sheldon Whitehouse (D-RI), and U.S. Reps. Rosa DeLauro (D-CT), Joe Courtney (D-CT), Elizabeth Esty (D-CT), Jim Himes (D-CT), and John Larson (D-CT). Brown and DeLauro are authors of the Medicare Advantage Participant Bill of Rights, legislation that was developed as a result of UnitedHealth’s unprecedented dropping of doctors from their Medicare Advantage networks, including the entire Yale-New Haven Hospital network.

“Today’s report underscores the horror stories I’ve heard from too many seniors,” Brown said. “When seniors sign up for a Medicare Advantage plan, they should be able to trust that they’ll be able to visit the providers listed. But thousands of doctors, providers, and sites of service have been removed without cause from MA plan networks after seniors have enrolled. This sort of blatant bait and switch should not be allowed. Medicare Advantage enrollees should be able to select a plan with an adequate provider network that meets all of their‎ needs and should have the security that their providers will not be dropped from the network in between enrollment periods.”

“This investigation shows what I have long said: Medicare Advantage patients have no recourse to stop bad behavior like we saw in Connecticut with UnitedHealth,” DeLauro said. “Soon I will be reintroducing the Medicare Advantage Participant Bill of Rights this year to ensure that we hold these companies accountable and put our seniors first.”

“This report tells us what many of us have longed suspected – CMS has failed to conduct rigorous reviews of the provider networks in Medicare Advantage plans, allowing insurance companies to drop thousands of doctors and other providers from MA plan networks, needlessly disrupting the care of seniors across the country. We must hold CMS accountable for their laziness and their appalling lack of scrutiny, which has endangered millions of seniors’ ability to access to health care,” Blumenthal said.

“Seniors have the right to a transparent continuum of care, including the right to know in advance when their health insurance plan no longer covers the care provided by their doctor,” said Esty. “The Government Accounting Office’s report on whether enhanced government oversight of provider networks is necessary makes it clear that improvements are needed to the oversight of Medicare Advantage organizations, like United Health Care. We must do more to ensure full access of care for our seniors.”

GAO’s recommendations were for CMS to:

  • Address provider availability in MA networks
  • Verify provider information
  • Review network information more often
  • Set minimum information requirements for the notification letters that go to patients