CMS Is Cracking Down on Medicare Advantage Provider Directories—and the Implications Are Bigger Than Many Realize
By: N. Adam Brown, MD MBA, CMO Radiant Healthcare
A new rule from the Centers for Medicare and Medicaid Services (CMS) is drawing renewed attention to an issue many providers, staffing firms, and health system leaders have quietly struggled with for years: inaccurate Medicare Advantage provider directories.
At its core, the rule is about accuracy and accountability. But its downstream effects will be felt well beyond Medicare Advantage plans themselves, particularly by provider groups and organizations responsible for enrollment functions.
Let’s be clear about what CMS is requiring, why it matters, and how organizations should be thinking about compliance.
What CMS Is Requiring—and Why
Medicare Advantage (MA) plans are required to maintain “network adequacy,” meaning they must have enough enrolled, in-network physicians to meet the needs of their beneficiaries. In theory, this requirement ensures access to care. In practice, however, some plans have historically overstated their networks by leaving “ghost providers” in their directories. (Ghost providers are physicians who may have retired, moved, lost privileges, or even died.)
CMS has had enough of that fraud.
Under the new rule, CMS is requiring MA plans to maintain accurate, current provider directories and to verify provider enrollment status within 30 days. In other words, MA plans must now be able to prove that the clinicians listed as in-network are actually enrolled, credentialed for enrollment purposes, and eligible to bill the plan.
This update is not purely cosmetic. It is a compliance mandate designed to prevent misleading network representations and to protect beneficiaries from being told a clinician is “in-network” when, in reality, they are not.
Why This Matters—and Where Confusion Creeps In
The medical community must also understand what this rule is not about. It is:
Not a hospital privileging issue.
Not traditional medical staff credentialing for clinical practice; and it is
Not relevant to nursing or allied health staffing since government and commercial payers do not reimburse nurses directly.
This rule is about provider enrollment, specifically enrollment in Medicare Advantage plans,for physicians and other prescribers who bill those plans.
That distinction matters because many organizations use the word “credentialing” loosely. When clients say they are “credentialing,” the real question is: credentialing for what purpose? Clinical practice? Hospital privileges? Or payer enrollment?
CMS’s rule applies squarely to credentialing for enrollment purposes, and that is where the operational burden sits.
Who Must Comply with This Rule?
While CMS is holding MA plans accountable, the operational reality is that the work will cascade downstream. This rule is directly relevant to:
Medical groups that rely on MA reimbursement;
Back-office organizations that perform enrollment functions on behalf of providers;
Physician staffing firms, such as large multispecialty staffing organizations, that bill for services;
Provider staffing firms whose hospital clients require enrollment support; and
MA plans themselves, which are now highly incentivized to clean up and validate their rosters.
For these groups, inaccurate or incomplete enrollment files are now a significant financial risk. Why? While the intent of the rule is to regulate MA plans, the practical consequences land squarely on providers and the organizations that support them.
If a physician is not properly enrolled in a MA plan, the could be several severe outcomes::
The provider may be removed from the MA plan’s director;y
Claims may be denied;
Reimbursement may be delayed or lost; or
Administrative costs could increase as teams scramble to fix enrollment gaps.
No provider group wants to discover a problem only after denials start arriving. And while it is unlikely that a staffing firm would sideline a physician over a single payer enrollment issue—particularly if that physician is enrolled with Medicare, Medicaid, or other commercial payers—the financial and operational friction could add up quickly.
How Organizations Should Be Thinking About This Rule–and Where Radiant Can Help
From a leadership perspective, this rule raises a simple question: Are your enrollment files accurate, current, and defensible?
CMS has effectively shifted the burden of proof. Medicare Advantage plans must prove accuracy, and, increasingly, these plans will require that their provider partners to do the same. That expectation means more frequent roster validation, tighter documentation standards, and faster turnaround times.
At Radiant Healthcare, we help organizations succeed during these types of regulatory shifts.
Our teams perform enrollment-related credentialing for tens of thousands of clinicians each year. We focus specifically on enrollment accuracy—ensuring providers are properly enrolled, documentation is complete, rosters are current, and compliance requirements are met.
As CMS raises the bar for MA plans, providers, hospitals, and staffing organizations will need partners who understand the difference between clinical credentialing and enrollment credentialing—and who can operate at scale without sacrificing accuracy.
The Bottom Line
CMS’s new rule is significant. Medicare Advantage plans can no longer rely on inflated directories, and providers can no longer assume enrollment errors will quietly go unnoticed.
Accuracy is now a compliance requirement, not a best practice.
Organizations that get ahead of this shift by tightening enrollment workflows and ensuring accurate documentation will avoid unnecessary denials, administrative churn, and revenue disruption. Those that do not will feel the impact quickly.
