REAL Act Compliance Scoring Methodology
real-act/v1This page describes how Fonteum computes MA plan directory accuracy compliance scores under the REAL Act. Scores are informational and not an official CMS compliance determination.
Regulatory Context
The Reducing Barriers to Medicare Beneficiary Access to Home and Community-Based Services Act (REAL Act, enacted as part of the Consolidated Appropriations Act) amends §1852 of the Social Security Act and imposes directory accuracy requirements on Medicare Advantage organizations under ACA §1002 and its implementing regulation at 42 CFR §422.111.
CMS enforces directory accuracy via quarterly audits. Plans with inaccurate provider directories face civil monetary penalties under 42 CFR §422.750. A "ghost network" — where listed providers are not actually accepting the plan's patients — is a recognized category of directory inaccuracy subject to enforcement.
Directory accuracy requirements include: provider name, specialty, address, phone, and whether the provider is accepting new patients. Fonteum's scoring covers the first four dimensions using cross-source federal data.
Data Sources
Primary provider identity + practice address + specialty. Self-reported by providers. Updated continuously.
https://nppes.cms.hhs.govCMS-curated provider data. Used for Care Compare presence check (ghost-network proxy) and cross-source field agreement.
https://data.cms.gov/provider-dataMedicare enrollment status. Used for field-level accuracy cross-check via the PDAI engine.
https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/medicare-fee-for-service-public-provider-enrollmentAuthoritative list of Medicare Advantage contracts (H-numbers), plan names, and states. Annual release.
https://www.cms.gov/medicare/plan-choice-and-enrollment/plan-landscape-filesScoring Formula (real-act/v1)
| NPIs in Fonteum ∩ plan | / | plan NPIs |Fraction of the plan's NPI roster that appears in Fonteum's cross-source data. A low completeness score indicates the plan is listing providers that do not appear in federal public records.
| NPIs with NPPES update ≤ 90 days | / | plan NPIs |Fraction of plan NPIs with a NPPES update in the past 90 days. Stale NPPES records are a leading indicator of directory inaccuracy; CMS's 90-day update cadence is the regulatory benchmark.
mean(PDAI field-level agreement score per NPI)Mean field-level agreement rate from the Provider Directory Accuracy Index (PDAI) engine. Covers practice address, specialty, organizational affiliation, and phone number (NPPES vs Care Compare vs PECOS).
1 − (| NPIs absent from Care Compare | / | plan NPIs |)Inverse ghost-network exposure. A score of 1.0 means all plan NPIs appear in CMS Care Compare data. A low score means many listed providers have no CMS-curated record — a proxy for ghost-network risk.
mean(completeness, currency, accuracy, ghost-network safety)Equal-weight average of the four sub-scores. Plans with fewer than 50 matched NPIs are flagged as insufficient-sample and excluded from the ranked leaderboard.
Compliance Grades
| Grade | Composite Score | Interpretation |
|---|---|---|
| A | ≥ 90% | Strong compliance posture — low audit risk. |
| B | 80–89% | Good posture — minor gaps worth addressing. |
| C | 70–79% | Moderate gaps — elevated audit exposure. |
| D | 60–69% | Significant gaps — high audit risk, recommend remediation. |
| F | < 60% | Critical gaps — plan likely to face CMS scrutiny. |
Limitations
- State-level NPI approximation:real-act/v1 uses NPIs active in the plan's primary state as a proxy for the plan's NPI roster. The CMS MA plan-to-provider crosswalk (plan-level NPI mapping) is queued for real-act/v2.
- Not an official CMS determination:scores reflect Fonteum's analysis of federal public records. CMS audits use proprietary plan data.
- Accepting-new-patients dimension: this field is not reliably published in NPPES or Care Compare at scale; excluded from real-act/v1.
- Refresh cadence: scores are computed quarterly, same cadence as PDAI. Point-in-time accuracy; plans may update their rosters between issuances.
Compliance posture
We don’t sell ranking and don’t accept payment to move a provider up the list. For final hire decisions, verify licensing, insurance, and references directly with the applicable licensing or credentialing body.
No bulk-licensing source family is currently ingested for this vertical. Hire-time checking still routes through the body named above.