Case Study

A Tale of Two Networks

An accidental A/B test reveals there are two ways to build a network — and one of them’s a nightmare.
Client

A Managed Care Organization (MCO) expanding into new lines of business.

Challenge

Having struggled to build a Medicaid network, they now faced the more complex requirements of Medicare — with only one shot to get it right.

Solution

QUEST ENTERPRISE SERVICES (QES):
The Enterprise-wide SaaS platform measures, manages and monitors network adequacy and provider data accuracy while enhancing cross-team communication, increasing network transparency and streamlining compliance.
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THE SITUATION

A Managed Care Organization (MCO) in a large Mid-Atlantic state wanted to expand into new lines of business. To do so, they needed to build two new provider networks: one Medicaid and one Medicare.

They started with the Medicaid network, using the tools they had on hand. As the network team describes it, the process was less than ideal.

“Trying to figure out which providers would close gaps for us in which areas … there was a lot of Google search, honestly. There’s a state provider database for us to use too, but a lot of the data is incorrect. They have doctors who have passed away, moved, or things like that. So a lot of manual research went into trying to figure out how to set up that network.”

Taking the same approach to the more complex Medicare Managed Long-Term Care (MLTC) network seemed like a recipe for disaster.

“It’s a lot more difficult on the Medicare side because of the time and distance requirements. And if we didn’t meet the requirements, we wouldn’t know about it until we actually submitted our network to the Centers for Medicare & Medicaid Services (CMS). Our application would get denied, and we wouldn’t get another shot until the following year. That’s why we started looking at Quest Analytics.”

THE SOLUTION

The client came to us already knowing what they wanted: Quest Enterprise Services, our SaaS-based provider network management platform. Members of the team had used the platform while working with a large national payer. They knew it would streamline their ability to build the network by allowing them to measure, manage and monitor network adequacy — and provider data accuracy — with unmatched efficiency.

“Quest Analytics is the gold standard, and the fact that CMS also utilizes them just made it a no-brainer.”

With the Medicaid experience still fresh in their minds, they turned to the Medicare network — but this time armed with tools and capabilities tailored to the task. The difference would be night and day.

The Outcomes

Building Provider Networks smarter, faster, and more cost-effectively.

“It’s been a lot easier for us to set up this provider network. It’s much easier to figure out which providers are going to close our specific specialty gaps because all that data is right there in Quest Enterprise Services. You just click on the specialty you need and it tells you which providers can close the gap.”

To take it a step further, the client no longer has to rely on guesswork and hope about which provider will add the most value to the network. With Quest Enterprise Services, they have data-backed intelligence on which provider will close the gap in one county and in the surrounding counties—allowing them to spend less time searching and more time expanding.

“It’s no longer a guessing game for us. It’s a factual platform that lets you know this provider will fill gaps in several counties, as opposed to a provider who’s only going to do it in this particular county. The efficiency of that is huge for us.”

Since implementing Quest Enterprise Services, multiple teams have been able to focus more on their core business—providing quality healthcare services—and less on trying to find out who can do what.

“Quest Enterprise Services allows my contracting team to spend their time more effectively. They are actually contacting the providers that are going to get us to where we need to be, instead of potentially wasting time trying to contract with providers that won’t. It saves a tremendous amount of time.”

Advanced Insight into Network Adequacy

As a health care provider, it’s important for the client to know how well their provider network covers the community they serve. Are there enough doctors? What about specialists? Is there enough capacity? With the Quest Enterprise Services, the client has access to a dashboard that tracks all of this information with ease.

“Before Quest Analytics, when the Executives would ask about network adequacy, I wasn’t 100% confident in the answers I would send them. Now, I can actually give them legitimate numbers that represent how adequate we are in any particular county. I’m much more confident in our numbers on the Medicare side because I can confirm them. I can see in real-time where we are and what gaps we’re closing. With the Medicaid side, we keep a manual spreadsheet. We submit it quarterly, and we don’t know where we stand until the state sends us the results. And then you have a very short period of time to correct those gaps — when we didn’t realize that they existed in the first place.”

By seeing the true status of the network and having access to historical data, the teams know how the network is operating at all times — not just quarterly or annually. And this allows them to make better decisions about where their resources need to be allocated.

CMS Compliant Confident

We know that CMS also uses Quest Analytics. So what we’re putting in there, we know that CMS is going to see the same thing. There’s not going to be any surprises.”

Future Forward

With multiple teams within the organization experiencing the benefits of Quest Enterprise Services, the client is now looking to expand their use of Quest Enterprise Services for additional lines of business.

“I understand there is a Medicaid solution offered through Quest Enterprise Services, and that’s something that would be very useful for us.”

MOVE FASTER, BUILD SMARTER

Want to expand into new counties? Launch new products? Grow your network of providers? Let us show you how Quest Enterprise Services helps you pinpoint the right opportunities for your business goals in just a few clicks of a button. Schedule a complimentary strategy session today!

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