Case Study

Growing Nowhere Fast

Learn how this health plan accelerated it’s expansion into new counties and states.
Client

A leading regional health plan

Challenge

To quickly expand multiple lines of business into new counties and states, the health plan needed a faster, easier, and more cost-effective way to build adequate networks.

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

One of the nation’s largest not-for-profit health plans saw a significant opportunity to expand into new counties and new states. But like many plans in their position, their ability to quickly find the right providers to build adequate networks with the needed degree of efficiency fell far short of their ambitions — a fact quickly discovered by the network manager who was brought into the company to lead the expansion.

“When I got there, I asked the team, ‘How do you currently identify providers?’

They told me, ‘We Google them.’

So I asked, ‘How do you know when the network is adequate?’

They responded, ‘Well, we sorta … we’re not quite sure, you know? We fill out these HSD tables…

“I told them, ‘This is nuts. There’s a scientific way to do this.’”

He called Quest Analytics.

THE SOLUTION

We set him up with our Quest Enterprise Services solution (QES), a SaaS-based provider network management platform that allows health plans to measure, manage and monitor network adequacy, provider data accuracy and access. Users can also use the tool to build new provider networks or expand existing networks.

QES made it possible for the health plan to view in real-time their provider network adequacy and track its progress over time while providing the tools and insights needed to demonstrate to payers their compliance with federal and state network adequacy requirements. The team could now strategically plan for expansion opportunities, review their existing network breadth and perform targeted analyses.

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The Outcomes

No more Googling to find providers.

“Instead of hunting, searching and looking for providers — and somewhat guessing on how we get to network adequacy — we now have a targeted way to identify the providers needed to meet regulatory requirements, by specialty type, in a given county.”

They’re recruiting smarter.

By using the Provider Impact Analysis feature in the Quest Enterprise Services, they can easily prioritize their recruiting to quickly and effectively fill gaps. Additionally, they can better understand the value of each provider in their existing network while performing ongoing network management.

“Here is [a county]. Here are the neurosurgical groups. By looking at a group, it [Quest Enterprise Services] can tell me, if one provider closes the network gap, or if I need multiple providers to close the gap.

Or even if I contract with all of them, will I still not get to 90%?

That’s what the tool does for me.”

They’re negotiating with better knowledge.

By using the Provider Termination Analysis along with the Provider Impact Analysis in the Quest Enterprise Services, they are able to quickly generate “what-if” scenarios that allow them to understand whether or not their network will remain adequate if they were to terminate a contract with a provider or group.

“The Quest Enterprise Services tool allows us to take our current providers in a county and eliminate this system or this group from that list and run a scenario that says, ‘When you remove XYZ health system, you no longer meet network adequacy in these specific specialty and county combinations.’ I’m able to see what percent of that network will have gaps and which providers will enable me to close those gaps. Having that information has allowed us to better understand our position during contract negotiations.”

They know exactly where they stand on adequacy — because the regulators use our tools, too.

“As we input the information into the Quest Enterprise Services tool and generate reports, we know how close we are to network adequacy in every county for Commercial, Medicare and Medicaid. We won’t file unless we’ve met network adequacy. It isn’t, ‘Let’s submit it and hope we get there.’ We know before submitting it that we’re there.”

And they’ve dramatically accelerated their speed to market.

In less than three months, they were able to build and submit a new state network. At the same time, they expanded their current footprint in their home state from 8 counties to 22 counties. Now that they have a proven system for expansion, they are working on moving into 40 counties and 4 new states.

In terms of operational efficiency, whatever the highest score you can give a product is what I would give Quest Analytics. Instead of spending hours and hours of time, and paying people to build the database to know who to go after: all the time is spent going after the providers we need to get to network adequacy. So it’s streamlined the process. We’ve saved a ton of money.”

Move Faster. Build Smarter.

Discover how Quest Enterprise Services can give you the tools you need to quickly and easily identify opportunities in the market—and those providers who will make all the difference in your success.

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