Case Study

Too Bad to Ignore, Too Big to Fix

A Managed Vision Care Company Tackles Provider Data Complexities
Client

A Leading National Managed Vision Care Company

Challenge

Provider data accuracy issues could have jeopardized their partner relationships — but they didn’t have an effective way to address them.

Solution

QUEST ENTERPRISE SERVICES (QES):
The enterprise-wide SaaS platform measures, manages and monitors network adequacy and provider data accuracy while enhancing cross-team communication, increasing network transparency and streamlining compliance.
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THE SITUATION

When the Centers for Medicare & Medicaid Services (CMS) began reviewing provider directory accuracy, one of the four specialties they targeted was ophthalmology. This was a wake-up call for a leading Vision Managed Care company. They knew they had data accuracy challenges, and the audits by CMS— along with similar compliance requirements by state regulators — meant it was only a matter of time before those issues caused problems for their partner health plans, which rely on that data to be accurate.

As they began to address improving their provider data, they experienced challenges. First, recent mergers quintupled the size of their provider data challenges and they didn’t have enough bandwidth to manage those appropriately. Second, a scalable solution was needed for accuracy management going forward.

“Our network had grown from about 30,000 providers to over 150,000 providers nationwide,” said the provider network manager. “We’re now required to do at least quarterly updates and outreach to 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 a two-pronged approach. To address the immediate concerns, Quest Analytics’ Outreach team took on the task of validating their provider data. Both to correct what’s inaccurate and to implement a process for ongoing validation that would comply with federal 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 Analytics Outreach Team Helped the Client Identify Incorrect Data and Correct It

“Our directory accuracy has greatly improved…Trying to meet these regulatory requirements just wasn’t possible until we engaged Quest Analytics.”

Streamlined Data Accuracy Management

“We’re getting the validated data back in a format that enables us to batch flow changes into the system. These efficiencies are a huge leap forward in getting our data to an acceptable standard of accuracy and then maintaining it.”

The Client Can Focus On Network Management and Strategy Initiatives

“The constant validation of provider data by Quest Analytics reduces our workload significantly. We can focus our attention on other network measurement and strategy activities that we need to do. For example, identifying gaps in our network and then working with the appropriate team members on action. We’re proactive rather than simply keeping the data up to date.”

Transformed Ability to Identify and Fill Network Adequacy Gaps

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

Better Provider Networks — and Better Member Experiences

“We update our source files monthly. Our leadership can look at our network status in QES at any time and see our network adequacy is improving.”

15-Plus Health Plan Expansions

“We just did 15-plus health plan expansions and new implementations in a very short amount of time. There is no way we could have done it without QES.”

MOVE FASTER, BUILD SMARTER

Want to expand into new counties? Launch new products? Grow your network of providers? Let us show you how Quest Enterprise Services helps you pinpoint the right opportunities for your business goals in just a few clicks of a button. Schedule a complimentary strategy session today!

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