Oversight, Meet Insight

A large state regulator finally gets the tools it needs to do the job right.

The Situation

A state insurance department had responsibility for regulating more than two dozen PPO networks — but their traditional tools left them operating largely in the dark.

“We were relying on paper (antiqued) GeoAccess reports provided by the insurers themselves to assess the adequacy of the networks, and 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 and find relevant information.”

What they wanted — and found — was Quest Enterprise Services.

The Solution

Quest Enterprise Services is a SaaS-based provider network management platform built to measure, manage and monitor not just network adequacy — which our customer knew it needed — but provider directory accuracy as well. Very quickly, they would come to see the value of managing both, together.

The Outcomes

Quest Enterprise Services has given them unprecedented insight into network adequacy.

“Quest Analytics has data regarding the providers and facilities available to fill holes in the 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.”

It lets them evaluate directory accuracy, too.

“That was sort of an ‘added bonus’ we hadn’t thought about. Quest Enterprise Services compares the network data to the Quest Analytics’ data to see if there are discrepancies, which gives us the ability to identify accuracy problems.”

By having a lens into the provider data, they can now 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.”

It lets them compare performance across plans.

“Before Quest Analytics, we did not have that capability to compare plan performance in one snap-shot. It was beyond our wildest dreams. Now, in addition to seeing how many providers there 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.’”

Quest Enterprise Services gives them the ability to time stamp submissions which allows them to analyze trends in the market and across plans.

“We’re hoping that over time we’ll get insight into trends that will help us provide advice to the legislature regarding public policy.”

And it’s giving healthcare consumers a better member experience.

“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.”

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.

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