Oversight, Meet Insight
A large state regulator goes from manual oversight to automated insight
Who We Helped
A Large State Department of Insurance
They had manual oversight of provider network adequacy—but zero insight into provider availability, provider data accuracy or performance across health plans.
Reliable Experts, Solving Problems:
A state insurance department had responsibility for regulating more than two dozen Preferred Provider Organization (PPO) networks — but their traditional approach left them operating largely in the dark.
“We were relying on manual reviews using paper (antiqued) GeoAccess reports provided by the insurers themselves to assess the adequacy of the networks. We felt this was insufficient for a number of reasons. One, we didn’t have the confidence that would come from having an outside vendor perform this analytics process.
“We also wanted something that was more flexible and more granular than doing a network analysis on a very high-level, nonspecific basis. We wanted to be able to identify areas of insufficient network adequacy for specific specialties, much like the federal government does in its programs.
“We wanted something we could use to perform analytic inquiries, to be able to ask questions and dig down deep into the data to find relevant information.”
What they wanted — and found — was Quest Enterprise Services.
Quest Enterprise Services is a SaaS-based provider network management platform built to measure, manage and monitor not just provider network adequacy — which our customer knew it needed — but provider directory accuracy as well. Very quickly, they came to see the value of managing both, together.
Unprecedented Insight into the General Availability of Providers
“Quest Analytics has data regarding the providers and facilities available to fill gaps in the provider networks. We can now say, ‘You don’t have enough cardiovascular surgeons here. There are 25 of them available in the market for that county. This ability puts us on a more even playing field with the health insurers in terms of the knowledge each of us has regarding availability.
“Also, when no one is successfully contracting, it’s meaningful for us to get confirmation of what we’re told anecdotally by the insurers — because sometimes these facilities won’t contract at all.”
New Capabilities to Evaluate Provider Directory Accuracy
“That was sort of an added bonus we hadn’t thought about. Quest Enterprise Services compares the health insurers’ data to the data in its system to see if there are discrepancies, which gives us the ability to quickly identify problems with the accuracy of the information.”
By having a lens into the provider data, the client is able to see and say, “These providers are deceased, these providers no longer have licenses, this address isn’t good, and this provider is practicing in 20 areas and has 20 addresses. We know this can happen, but now we can raise that question to the insurer to see if there’s actually a problem. It lets insurers know that we are vigilant in that regard and helps them produce a provider directory that will be of actual use to consumers.”
Streamlines Comparing Multiple Plans
“Before Quest Analytics, we did not have the capability to compare plan performance in one snap-shot. It was beyond our wildest dreams. Now, in addition to seeing how many providers are in a particular geography, we have insight into the adequacy of other plans in a market. We can say, ‘Well, everyone else can meet that requirement. Maybe it’s something about what you have to offer that’s the problem.’”
Key Market Trends To Improve Public Policy
“We’re hoping that over time we’ll get insight into trends that will help us provide advice to the legislature regarding public policy.”
Better Position to Protect Consumers
“The reason I cherish it is that it’s made us more effective. We’re finding more real problems that affect people, especially in the specialty areas. We bring adequacy and directory issues to the insurer’s attention and — because of our persuasive power as the regulator — they fix them.
“It’s enabled us to do a better job and to protect consumers better.”