What is Triennial Network Review

Triennial Network Review Definition

The Triennial Review is the "Stress Test" of a payer’s Network Management infrastructure. For C-level Executives, it is a high-stakes audit where the plan’s historical data is scrutinized for accuracy and consistency. Unlike the annual bid review, which is often automated, the Triennial Review can include deep-dives into "Primary Source Verification" files, "Contract Accuracy," and "Directory Validity." Operationally, the challenge is proving that the network was adequate at all times during the three-year period, not just at the time of the audit. This requires an impeccable "Audit Trail" within the Provider Lifecycle Management system. If a plan fails the Triennial Review, it can face permanent "Enrollment Caps" or be forced to exit certain markets. Strategically, successful plans use the "Off-Years" to conduct "Mock Audits," ensuring that their provider data remains "Audit-Ready" at all times.

FAQs

What is the primary focus of the Triennial Review?

CMS looks for "sustained adequacy," ensuring the plan has maintained time/distance standards and provider-to-member ratios despite provider turnover and membership growth.

How does "Directory Accuracy" play into the Triennial Review?

Auditors will often perform "Secret Shopper" calls to providers in the directory to verify that the information the plan has on file matches the reality of the doctor’s office.

What happens if a plan fails to resolve a deficiency found during a Triennial Review?

Continued failure can lead to the termination of the plan’s CMS contract, effectively ending their ability to participate in the Medicare Advantage program.