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.

The Situation

A managed long-term care program 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, 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], too, but a lot of the data is incorrect. They have doctors who have passed away or moved or things like that. So a lot of really manual research went into trying to figure out how to set up that network.”

Taking the same approach to the more complex Medicare 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 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.”

The Solution

The customer 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, and they knew it would streamline their network build by allowing them to measure, manage and monitor network adequacy — and now provider directory accuracy — with unmatched efficiency.

“Quest is the gold standard, and the fact that CMS also utilizes them just kinda 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

They’re building smarter, faster, and more cost-effectively.

“It’s been a lot easier for us to set up this network. It’s much, much, much easier to figure out which providers are going to close our specific gaps — because all that data’s right in there. You just click on the specialty you need and it gives you 100% who’s going to cover the gap. So it’s not a guessing game; it’s a factual platform where you can grab that provider and know you’re going to close that gap.

“It lets you know that this provider will actually fill gaps in several counties, as opposed to that one who’s only going do it in this particular county. The efficiency of that is huge for us.

“It allows my contracting team to spend their time more effectively, 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.”

They know exactly where they stand on adequacy.

“Before Quest, the C-suite would ask me for updates on network adequacy, and I would just sort of fudge it a little, to be honest with you. 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. I mean, with the Medicaid side we keep a manual spreadsheet. We submit it quarterly, and we don’t know where we stand until the state spits it back out and says, okay, these are all your gaps. And then you have a very short period of time to cure those gaps — when we didn’t realize that they existed in the first place!”

They’re no longer worried about CMS.

“We know that CMS also uses Quest. 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.”

And they have hope for an even better future.

“I understand there is a Medicaid solution offered through Quest, and that’s something I’ve been trying to convince the C-suite would be very useful for us ….”

EDITOR’S NOTE: Quest Enterprise Services actually works across product lines. That means our customer will be able to manage the adequacy of all their networks — as well as their directory accuracy — from a single enterprise-wide dashboard. We look forward to helping them do that.

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