“Are We Compliant – or Not?”
It was time to take the guesswork out of CMS and state adequacy requirements.
A health plan offering MA and Medicaid products in a major metropolitan area
They had no effective way to find their own adequacy gaps — but CMS and state regulators were finding plenty
“If somebody were to ask us, ‘Do we have an adequate network in this county?,’ there didn’t seem to be a way for us to confidently say yes or no.”
For the network operations manager at a large metropolitan health plan, that was the elephant in the room — as it is for a lot of plans. They have no way to know for sure they’re meeting adequacy requirements — until the audit.
“I honestly don’t know how we were getting by. It wasn’t clear to me how anybody confidently knew what our network would look like outside of just saying, ‘We have a lot of providers, let’s submit it to CMS and see where the gaps are.’
“And we had an incredibly high number of gaps. But a lot of those gaps were actually not gaps. They were just problems with the way we were doing the reports and coding.”
So the health plan needed two things: A reliable way to measure network adequacy in real time, and an easier, more accurate way to create regulatory reports.
Quest Enterprise Services delivered both.
Quest Enterprise Services was built for situations like this. It’s an enterprise-wide provider network management platform that allows health plans to measure, manage and monitor network adequacy — and provider directory accuracy.
They know exactly where they stand on adequacy — at all times.
“CMS has the contract with Quest Analytics to do their own analysis and so does [our state’s] Department of Health. So the tool they use to measure our adequacy is the same tool we use internally. That means we don’t run into any surprises. We know that what we get with Quest Analytics is going to be the same result we get when CMS or the state does it.”
They’re producing accurate regulatory submissions — in record time.
“An HSD report would have taken us a week and a half or two weeks to put together. We’re doing it now in an hour — so that’s a pretty significant improvement.
“On the [state] side, it would take us, without exaggeration, three to four weeks to put together a file — and those are due every quarter. Now we’re down to a day and a half to get the files done. So just for internal efficiencies, it’s allowed us to really focus on other areas of our business that we couldn’t get to before because of all the regulatory requirements.”
They’re closing their gaps — fast.
“Having those provider lists, those leads, it’s incredibly valuable because you’re not worried about, ‘Oh, they’re in that area and maybe they’ll solve the time and distance.’ The tool is telling you, ‘If you get this provider, this location, you’ll be all set.’
“We made up a lot of ground on our network gaps just by seeing — especially on some of the hospital-related services — that we already have providers who should be filling this gap and they’re not. So without even having to recruit, we were able to solve a good amount of gaps — in days instead of months.”
They’re seeing results.
“On the Medicaid side, before engaging with Quest Analytics, we had about 150 total gaps. We’re now down to 9 total gaps. On the Medicare side, we had 47 network gaps across our HSD file. We’re down to 4 total gaps. So in terms of measurable improvements, those are pretty eye-opening numbers.”
Quest Enterprise Services has taken the mystery — and the fear — out of network adequacy.
“[A regulator] could email me on a Friday afternoon now and say we need a file by Monday, and we would be fine. Not only would we be fine, but we would also know exactly what they were going to find.”
MOVE FASTER, BUILD SMARTER
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