Too Bad to Ignore, Too Big to Fix

A vision managed care company confronts a provider data nightmare.

The Situation

When CMS began reviewing provider directory accuracy a few years back, one of the four specialties they targeted was ophthalmology. That was a wakeup call for a leading vision managed care company. They knew they had accuracy issues, and the CMS audits — along with similar moves by state regulators — meant it was only a matter time before those issues caused problems for their partner health plans, which rely on that data to be accurate.

But there were challenges: First, recent mergers had quintupled the size of their provider network — along with the size of their data problem — and they didn’t have the bandwidth to handle it. Second, even if they cleaned up their data, they had no scalable way to manage accuracy going forward.

“Our network had grown from about 30,000 providers to over 150,000 providers nationwide,” said the company’s provider networks reports manager. “We’re now required to do at least quarterly updates and actual outreach to the providers to validate their data. And that would take, I can’t even imagine how many people. We needed a better solution.”

The Solution

Enter Quest Analytics, with two solutions. First, our Outreach Services team took on the task of validating their provider data, both to correct the immediate problems and to implement a process for ongoing validation that would comply with new federal and state regulations.

Second, we moved their network data onto our Quest Enterprise Services platform, an enterprise-wide, SaaS-based solution that allows them to measure, manage and monitor both the accuracy and adequacy of their networks.

The Outcomes

The Quest Outreach team has helped them get a handle on bad data.

“Directory accuracy absolutely has improved. … Trying to meet these regulatory requirements, it just wasn’t going to be doable until we engaged Quest.”

The Quest Enterprise Services platform has streamlined accuracy management and monitoring.

“We’re getting the validated data back in a format that enables us to batch flow changes into the system. Those efficiencies, I mean, it’s a huge leap ahead in being able to get the data into an acceptable standard of accuracy and then maintain it.”

It’s allowed the customer to turn their attention to network adequacy.

“The constant validation of the data is taking a lot of the weight off the shoulders of our people and is allowing us to do these other measurement activities that we need to do to see where there are gaps and to get those to the network team and recruitment team and so forth. So we’re proactively doing these things rather than just constantly keeping the data up to date.”

It’s transformed their ability to identify and fill adequacy gaps.

“To be able to dive into a county in, say, New York and see right on the screen, ‘Okay, this provider will fill this gap 100%’ — I mean, before Quest that would have been an hour’s worth of work right there. It’s just so head and shoulders above what we were doing before that nobody can even believe it’s real.”

They’re building better networks — and better member experiences.

“We’re updating our source files on a monthly basis. And with leadership going in and looking at it, they can see that the adequacy is improving.”

And they’re building a more successful company.

“We just did 15-plus health plan expansions or new implementations in a very short amount of time. And there was no way we could have done it without having the Quest services that we have.”

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