Case Study

Meeting Medicaid Network Adequacy With Advanced Network Management Solutions

Who We Helped

A Medicaid Managed Care Organization (MCO) in Hawaii

Their Challenge

This MCO faced unique challenges in efficiently assessing and ensuring network adequacy and provider data accuracy for its Medicaid program.

Solution

This MCO worked with Quest Analytics®to transition from the Quest Analytics Suite®(QAS^®) desktop solution to our SaaS Quest Enterprise Services®(QES^®) to address their network adequacy requirements more effectively. Through the migration to QES, MCO achieved cleaner and more accurate data, streamlined reporting processes, and proactive gap identification and remediation.

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THE SITUATION

Faced with the challenge of adapting to new network adequacy requirements for a recent Medicaid contract, a Managed Care Organization (MCO) recognized the necessity for an advanced solution. Historically, the MCO employed a manual process dependent on its subject matter experts. However, due to staff turnover, this approach faced disruption, compelling the MCO to seek a more sophisticated and resilient solution to ensure compliance and operational efficiency.

THE SOLUTION

Recognizing the pivotal role of technology in overcoming these challenges, the MCO engaged Quest Analytics®, the leader in provider network management solutions. Leveraging the comprehensive capabilities of Quest Analytics, the MCO transitioned from solely using the Quest Analytics Suite™ (QAS®) to incorporating Quest Enterprise Services® (QES®). This strategic shift was instrumental in addressing network adequacy and provider data accuracy requirements.

QES offers a Geographic Distance Methodology, which is essential in meeting state network adequacy standards while facilitating the MCO’s data accuracy initiatives. The adoption of QES has empowered the MCO to align its operations with stringent compliance standards effectively. This transition not only ensures compliance but also positions the MCO for enhanced operational efficiency and data integrity, thereby driving substantial business growth and improved service delivery.

The Outcomes

Automated Network Adequacy Evaluations and Reporting

QES provides the MCO with 38 comprehensive reports, including specific Provider Network Adequacy reports. These reports offer in-depth insights into their network adequacy, eliminating the need for manual calculations of drive times for network adequacy evaluations. This improvement significantly enhanced the accuracy and reliability of the MCO’s reporting.

Enhanced Provider Data Quality

QES enabled the MCO to identify and rectify data discrepancies, significantly increasing data accuracy and quality. “Data speaks louder than anything – we can hear anecdotally through grievances. But with more accurate measures of network adequacy, we can see more across the board,” mentioned the MCO.

Proactive Network Gap Resolution

With the integration of QES, the MCO has achieved greater efficiency in identifying network gaps. The advanced data insights provided by QES facilitate quicker resolution times and allow the MCO to stay ahead.

“With Quest Analytics we finally got some clarity. Once the data was clean, we were able to use tools to help us not only address existing gaps but get ahead of them.”

The platform’s advanced analytics empowered the MCO to proactively address network inadequacies, reducing member grievances and ensuring timely access to care. The ability to quickly share reports with other teams and export data for further analysis also facilitated more comprehensive decision-making.

Enterprise Support and Collaboration

The MCO highly values the dedicated support from Quest Analytics, which extends across its other lines of business. The availability of a dedicated team and compliance resources contributed to a smoother onboarding process and improved user experience.

The QES platform’s accessibility to historical data also allowed for comprehensive analysis, empowering the organization to derive actionable insights across these lines of business.

“Historical data is more accessible and easier to dive into. We now have insights into how many providers there are for certain specialties and where they are located. The QES platform makes that so much easier to present. And, I’m also confident that I am using the right data.”

Trust in Data and Advanced Analytics

The MCO emphasizes the trust they place in the data quality of QES, which enables accurate reporting and decision-making. The platform’s advanced analytics capabilities assist the organization in identifying trends, measuring network adequacy, and gaining deeper insights into provider availability and distribution. This newfound visibility into provider data supported proactive decision-making and efficient resource allocation.

“We trust the data quality in QES for reporting and decision-making. It also showed the power of analytics to drive efficiencies and do data clean up.”

CONCLUSION

By leveraging the QES platform, the team was able to successfully address the challenges associated with network adequacy assessment for its Medicaid program. The transition from a manual approach to an advanced analytics solution streamlined reporting processes, enhanced data cleanliness, and facilitated proactive gap identification. The collaborative partnership between the organization and Quest Analytics exemplified the value of leveraging the QES platform to drive efficiencies and improve customer satisfaction. Further, because of their successful collaboration with Quest Analytics, this organization is now looking into extending QES into their commercial line of business.