Building Their Own HMO

A large urban metro health system finds the partner it needs to go it alone.

The Situation

A health system in the southeastern U.S. decided it was time to set up their own Medicare Advantage HMO. They’d been a contracted HMO for years, but going it alone meant they could expand their reach to all parts of their county and serve more people.

The challenge? They needed to build a new provider network as quickly and cost effectively as possible, recruiting heavily from outside their health system. They had no system in place for doing that, and as a contracted HMO, they’d had no experience managing the complexity of CMS adequacy requirements.

“We’d never had to create HSD tables and all of these things ourselves,” recalled a network manager. “But going into our own HMO and expanding to all zip codes [in the county], we needed to have our own system and a way to target outside providers.”

They gave us a call.

The Solution

We introduced the customer to our Quest Enterprise Services solution, a SaaS-based network management platform that allows plans to measure, manage and monitor network adequacy and accuracy while streamlining enterprise workflow.

By automating many of tasks required to build and manage a CMS-compliant network, it’s given our customer the skillset — and the confidence — to bring their new network to life.

The Outcomes

It simplified CMS adequacy requirements.

“You come into this thinking it’s a numbers thing — you need more providers — but when you’re talking about the distance component, it gets a lot more tricky. Having to figure out the average distance between one location and another based on how many people live in that area — that’s just incredibly time consuming. Quest does that for you. It drills into the different providers that are going to meet the distance component versus the specialty count. And if [providers meet both], it’s going to find you the best option.”

It prioritized target providers.

“The market provider list is an amazing feature. It narrows down to the providers that are going to give you the largest [adequacy] gain based on the specialty. Had we not had that feature, we would have spent more of our time looking at providers that wouldn’t have made an impact on what we needed. The ability to target those specific providers is so incredibly efficient.”

It guided the recruiting teams.

“It’s great to be able to pull a report and send it off to our folks who are working on that specialty and say, ‘OK, just focus on the highlighted green providers,’ and not have to get into the nitty gritty about this one having a higher impact on adequacy versus the other one. So it allows for an easy read, gives you the address and the phone number, so you can pull them up and you’re ready to go — without having to do the guesswork.”

It eliminated wasted effort.

“We had specialties where we thought we needed more providers, but when we ran the first report, we were surprised to find that we didn’t. We’d already met [the requirements] based on the distance regulation and the number of providers. We also had providers we’d already contracted with and didn’t know they had offices in other locations. The Quest system can show all of a provider’s locations — so it saved the time we would have spent looking for more providers.”

It flagged bad data.

“CMS requires valid addresses for the providers — and Quest made it very easy to identify those that we needed to fix. It finds issues right down to the NPI number. In fact, right now I have an NPI number that’s invalid — because I typed it in wrong. Without the Quest tool, I would not have been able to catch that because it was off by just one number.”

It helped them build their network — fast.

“Seven, eight months — and I would definitely say that’s fast.”

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