Uniting an Enterprise

They set out to solve adequacy — and built a stronger business along the way.

The Situation

When you’re one of the nation’s largest health insurers, meeting CMS adequacy requirements for your Medicare Advantage networks can be challenge enough. But when you’re also managing large Medicaid networks in multiple states, each with its own set of adequacy rules, the job can quickly overwhelm.

“There really wasn’t a mechanism to analyze network adequacy,” recalled a senior network manager — unless you count “hearing about [gaps] via an audit. … We wanted to have some sort of program oversight of our provider networks, a way to have continual monitoring and be able to demonstrate to regulators that we have a process in place in the event that we’re audited.”

They found only one solution on the market that could deliver what they needed: Quest Enterprise Services.

The Solution

Quest Enterprise Services is a SaaS-based provider network management platform that allows health plans to measure, manage and monitor network adequacy — and now provider directory accuracy, too. But as a multiuser cloud solution, it’s also designed to bring new efficiencies to the entire enterprise.

As a first step, our customer loaded their Medicare Advantage network onto the Quest platform and immediately began measuring adequacy against preloaded CMS templates. At the same time, “Quest worked with each of the local markets to identify the state Medicaid requirements, then built a custom template that allowed us to assess the Medicaid networks against the state requirements.”

Suddenly what had been an arduous and unreliable process — manually trying to find and fill network adequacy gaps across product lines — was automated and efficient. But as our customer soon discovered, the benefits were far broader than that.

The Outcomes

They’ve connected silos across the enterprise.

“It creates a central source of truth, so to speak. Instead of having multiple areas [of the company] assessing network adequacy, you have one central location that people can refer to, and you know the results are consistent.

“It also provides an opportunity for anyone to view whatever areas are relevant to their work. So it’s allowed us to partner more closely with the local markets to help them with our end goal of building these networks. You build more trust with your partners.”

They’ve taken control of network adequacy — for Medicare and Medicaid.

“It’s helping the contracting teams identify where there are gaps of access for members, and then close those gaps via the tool. It identifies potential providers to fill any sort of access gaps.

“And having this mechanism to continuously monitor adequacy, we’re addressing gaps more quickly than we would have in the past. We’re catching things quickly. And we’re able to be more proactive about maintaining our networks versus reactive. That’s important.”

They’ve streamlined regulatory reporting.

“The scale of all of the networks we have, I don’t really know how we would do it without the tool, to be honest with you. And by virtue of having a consistent reporting mechanism, you’re going to stay more compliant and be more proactive about addressing any gaps and making sure that your network provides access to all of your beneficiaries.”

They’re capitalizing more quickly on expansion opportunities.

“I’m not even sure how many new networks we’ve launched over the past few years, but we definitely use the Quest tool to support that. You can monitor [new networks] separately from your active service areas, and as you contract providers, you can refresh the data and see what progress you’re making.”

And they’ve built a stronger, more competitive organization.

“If you want to play and grow, you need to be compliant. You need to be foundationally sound. So we started there, and the Quest tool enabled us to achieve that. And once you have these capabilities, you can have more confidence in meeting the requirements and growing your business. And the Quest tool has helped with that as well.

“It’s been immensely helpful.”

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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