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 build adequate networks with any degree of efficiency fell far short of their ambitions — a fact quickly discovered by the network manager brought in to lead the expansion.
“When I got there, I said, ‘So how do you guys identify providers?’ ‘Oh, you know, we Google them.’ So I said, ‘How do you know when you get to network adequacy?’ ‘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.
We set up the customer with our Quest Enterprise Services solution, a SaaS-based network management platform that allows plans to measure, manage and monitor network adequacy — and now provider directory accuracy — while streamlining enterprise workflow.
No more Googling for providers.
“Instead of hunting and pecking and looking for providers — and somewhat guessing on how we get to network adequacy — we have a targeted way to identify providers needed to meet regulatory requirements, by specialty type, in a given county.”
They’re recruiting smarter.
“Here is [a county]. Here are the neurosurgical groups. By looking at a group, it can tell me, does one close the network gap or do I need multiple to close the gap? Or even if I got all of them in, will I still not get to 90%? That’s what the tool does for me.”
They’re negotiating with better knowledge.
“The Quest tool allows us to take our current providers in that county and eliminate this system or this group from that list and run a scenario that says, ‘Oh, guess what, you take out XYZ health system, you no longer meet network adequacy. You have the following gaps. What percent of the network has gaps? And what do we need to do to cure the gaps?’ So we’ve used that 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 tool and generate reports, we know how close we are to network adequacy in every county for Commercial and Medicare and Medicaid. And 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’ve been able to build and submit a new state network, and are now expanding into four additional states. At the same time, they’ve expanded in their home state from eight counties to 22, with 40 more planned.
“In terms of operational efficiency, whatever the highest score you can give a product is what I would give Quest. 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.”
Take the First Step From Adequate to Excellent
We partner with 95 percent of America’s health plans and have experienced the challenges of provider network design, optimization and management. We’ve built our platform by working side-by-side with you and working closely with CMS and more than 30 state regulatory agencies, independent review organizations and brokers. We know what the regulators are looking for and what tools your organization needs to build differentiated and excellent provider networks and member experiences. Contact us today and book a strategy session.