Case Study
How Enhanced Data Insights Helped a Health Plan Improve Healthcare Access
Who We Helped
A Southwest Regional Plan
Their Challenge
A Southwest Regional Plan is focused on addressing challenges like ghost providers and gaps in healthcare, which create unnecessary hurdles to care and prevent patients from getting timely healthcare services.
Solution
Expanding their relationship with Quest Analytics®, the regional plan leverages Quest Enterprise Services® (QES®) Provider Claims Insights (PCI) to address network challenges head-on. QES PCI adds claims data, including claims volume, provider efficiency and effectiveness scores, and Payer Mix to their already empowered data-driven solution to evaluate network adequacy and the ability to provide timely and accessible care for members.
THE SITUATION
When it comes to health, timing can be everything – and getting in the door is half the battle. Far too many patients are waitlisted for months to see a specialist or schedule a procedure. Members should be able to access the care they need at the right place and at the right time with ease. Unfortunately, the prevalence of “ghost providers” and the scarcity of certain specialties like behavioral health pose a considerable obstacle.
The health plan’s director of clinical network analytics and outcomes succinctly stated the challenge, “Maintaining network adequacy is a constant struggle. We need to ensure our members have seamless access to appropriate care providers, but it’s far from simple.”
The director also recognized that smaller practitioners in the plan’s network were at a disadvantage in contract negotiations with large hospital groups. Leveraging claims data and efficiency scores during provider negotiations could provide a level playing field for all providers and ensure sole practitioners aren’t sidelined due to a lack of resources or negotiation power. The inclusion of smaller practitioners could help create more robust networks, increasing accessibility and availability.
THE SOLUTION
Their director stressed the importance of claims data and efficiency scores as critical components in creating a comprehensive view of provider engagement: “I’m focused on the adequacy aspect of it and making sure that if a member needs to see a provider, they can get an appointment.” He also acknowledged the need for data to identify gaps in provider availability accurately.
The plan joined forces with Quest Analytics to collect claims data that can inform decisions around network building and ensure ghost providers aren’t delaying care.
BENEFITS AND RESULTS
Their director envisions leveraging the data provided through Quest Analytics in various ways, including connecting the data with their internal provider files, which will make it more accessible to various stakeholders. “I think that the sky’s the limit. Once I have a source of data, I can connect it to anything else and move it around.”
Their director also identified the broader impact of data utilization on member experiences, particularly in the behavioral health sector. He anticipates that the data will help identify providers who can effectively reduce appointment wait times and ensure timely access to care. “I think having QES’s claims data and the quality metrics is going to really help us focus on adding the right types of providers to these systems.” Their director envisions a future where data-driven strategies optimize network adequacy and appointment availability, ultimately leading to better patient experiences.
Overall, their director is excited about how the data gleaned through Quest Enterprise Services® (QES®) can assist in identifying gaps and making informed decisions in areas such as provider compensation, network expansion and appointment availability, “This data infusion is a game changer. Now, we have a clearer view of provider engagement and performance, allowing us to plug gaps and spotlight dedicated providers. It’s a treasure trove for identifying discrepancies and rewarding excellence.”
CONCLUSION
The plan is using the data to reshape how they navigate network adequacy challenges. Their endeavor is not just about regulatory compliance, but also about ensuring better member experiences. Armed with data-driven insights, they are poised to drive positive changes in their networks and ultimately provide more comprehensive care to their members.
Discover how Quest Enterprise Services® (QES®) Provider Claims Insights (PCI) can help you improve the value of your provider networks by ensuring it’s adequate, accurate, and active! Request a demo today and see actionable insights in real-time. Let us show you how data-driven solutions can make a measurable impact.
