Modernizing the Health Plan Compliance Workflow for Government Programs and Policymakers
Discover Why Over 30 Regulatory Agencies Trust Quest Analytics®
Network Adequacy and Provider Directory Accuracy Solutions for Healthcare Policy Makers
For nearly 20 years, we have partnered with federal and state agencies, policymakers, and Medicaid program leaders to implement a data analytics platform and processes to help them monitor the network adequacy and provider directory accuracy of issuers. Our long-standing contractual relationships with the Centers for Medicare & Medicaid Services (CMS) and state agencies have set industry standards for health plan network adequacy and provider data accuracy regulations. These relationships give us an understanding of the intricacies involved in health network assessments while simultaneously deepening our insight into policy trends and regulatory priorities.
Partnering with Regulatory Agencies Nationwide
More than 30 state agencies and independent review organizations, including the Departments of Insurance and Health and Human Services, work with us. Our advanced analytics and innovative data solutions enable these entities to fulfill their oversight responsibilities efficiently and effectively.
We actively collaborate with federal policymakers, State Insurance Commissioners, and State Medicaid Directors to develop innovative network adequacy and provider directory accuracy measures, including network adequacy telehealth credits. These efforts help agencies evaluate strategies that can improve access to care while maintaining meaningful oversight standards.
Modernize Your Network Adequacy Oversight Process
Quest Analytics® offers software to efficiently and cost-effectively analyze health plan provider data to determine compliance with agency specified network adequacy requirements.
Identify Network Adequacy Standards
Quest Analytics partners with your office to identify your state’s network adequacy requirements, resolve ambiguities, and translate those standards into defined compliance rules for analysis.
Create a Data Collection Template for Health Plans
Your Quest Analytics consulting team works with your agency to select or develop a provider data collection template that aligns with your regulatory requirements. The template may include leveraging a CMS template or creating a customized template tailored to your specific rules. Collected provider data elements can include provider names, NPIs, addresses (city, state, county, zip), specialties, and more. Quest Analytics then supports the collection of health plan data, uploads the data into Quest Enterprise Services® (QES)®, and prepares the environment for your network adequacy review workflow to begin.
Analyze Provider Data and Assess Regulatory Compliance
The QES dashboard provides a comprehensive view of health plan performance against network adequacy requirements. Review compliance by geography and provider type, identify access gaps, evaluate trends over time, and assess whether network deficiencies may be resolved through provider additions or approved exceptions. These insights support informed compliance determinations and broader access-to-care evaluations.
Communicate Compliance Results to Health Plans
QES makes it easy to share network adequacy results with health plans. You can generate and export reports that highlight areas of noncompliance to support productive discussions.
Within QES, you can also track and apply exceptions, helping you manage follow-up and make informed, final determinations on overall plan compliance.
Strengthen Network Adequacy with Data Quality Insights
Accurate provider data is critical to meaningful network adequacy oversight. QES helps identify potential data quality issues by flagging providers with unusually high numbers of practice locations, unclear specialty designations, or limited evidence of recent activity.
Your Partner for Oversight Success
Quest Analytics provides a group of consultants to guide your onboarding and configuration process and remain an ongoing resource. Through regular engagement, your team receives guidance on workflow optimization and policy alignment to help maximize the value of QES for network oversight and compliance monitoring.
Solutions for Government Programs and Health Coverage Oversight
We partner with regulatory agencies including the Centers for Medicare & Medicaid Services (CMS), the Center for Consumer Information and Insurance Oversight (CCIIO), and state agencies to deliver network adequacy solutions tailored for Medicare Advantage, Medicaid, and Commercial health insurance including Federal and State Marketplaces.
For nearly two decades, Quest Analytics has supported CMS in evaluating Medicare Advantage Part C and Part D provider networks. CMS conducts annual health plan network adequacy evaluations, as well as triennial reviews of participating health plans, to verify the accuracy of submitted network data. To streamline this process, CMS relies on Quest Analytics’ solutions to facilitate the review of Health Service Delivery (HSD) tables from participating plans.
Additionally, we work with CMS to help determine feasible standards based on geography and available providers by specialty – helping to eliminate unnecessary exception filings that take up scarce resources.
We work with dozens of State Medicaid Agencies to provide the data analytics solutions they need for network adequacy evaluations and oversight. Additionally, we assist them with the development and implementation of quantitative network adequacy standards and provider directory accuracy requirements. Given Quest Analytics’ knowledge of evidence-based quantitative network adequacy standards, our strong relationships with network adequacy leaders inside CMS, and our contractual relationships with Managed Care Organizations, Quest Analytics is in a strong position to offer expert assistance to any State in the development of standards.
Federally-facilitated Marketplace
We partner with the CCIIO to deliver data analytics solutions and services that assess network adequacy for Qualified Health Plan (QHP) certification. This is vital as 29 states participate in the Federally-facilitated Marketplace and must comply with network adequacy requirements. Our offerings enhance the agency’s ability to monitor compliance effectively while simultaneously deepening their insight into market trends and behaviors.
State-based Exchanges & States Applying for the Effective Provider Access Review Program
We partner with policymakers and regulators on State-Based Exchanges, offering solutions and services to assess network adequacy for QHP certification.
For states wanting to transition to a state-based exchange or apply for CMS’s Effective Provider Access Review Program (EPARP), Quest Analytics can help design and implement a compliant program from the ground up. We can help streamline the transition while ensuring a thorough understanding of the requirements and optimal processes. Agencies gain enhanced compliance monitoring capabilities and deeper insights into market trends and carrier behaviors along the way.
Procurement Options
To help your agency move quickly, save costs, and work within its preferred procurement framework, Quest Analytics is prepared to contract through any vehicle you choose. Beyond responding to a competitive RFP, these options include sole source, cooperative agreements (such as NASPO ValuePoint and GSA), subcontracting, or a direct award under your state’s competitive procurement threshold.
Sign Up For Our Regulator Newsletter
The network adequacy and provider directory accuracy regulatory landscape is constantly evolving. Our Government Programs Team tracks the legislation, rules, and guidance to help you stay informed on what is pending, finalized, and on the horizon.
Join Our Regulator Exclusive Webinars
Connect with fellow regulators, agency leaders, Medicaid administrators, oversight professionals, and policymakers in our Regulator Exclusive webinars, designed to address critical issues such as network adequacy and provider data accuracy. Learn about advanced strategies, share valuable insights, and collaborate to drive meaningful changes in the healthcare industry.
For more information, contact our Regulatory Team at Regulatory@questanalytics.com.
Solutions for Regulators
With Quest Analytics, government agencies, Medicaid contract administrators, and oversight organizations gain the data, reporting, and workflow tools needed to evaluate provider networks and monitor compliance. Schedule a consultation with our Government Programs Team to learn how QES can support your oversight objectives.