Case Study

Uniting an Enterprise

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

A large Blues plan offering MA and Medicaid products in multiple states


Struggling to meet the diverse adequacy requirements of CMS and states, the plan needed a smarter way to work


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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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.


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

It simplified CMS adequacy requirements.

“You come into this thinking it’s a numbers thing — you need more providers — but when you’re talking about the distance component, it gets a lot more tricky. Having to figure out the average distance between one location and another based on how many people live in that area — that’s just incredibly time-consuming. Quest Analytics does that for you. It drills into the different providers that are going to meet the distance component versus the specialty count. And if [providers meet both], it’s going to find you the best option.”

It prioritized target providers.

“The market provider list is an amazing feature. It narrows down to the providers that are going to give you the largest [adequacy] gain based on the specialty. Had we not had that feature, we would have spent more of our time looking at providers that wouldn’t have made an impact on what we needed. The ability to target those specific providers is so incredibly efficient.”

It guided the recruiting teams.

“It’s great to be able to pull a report and send it off to our folks who are working on that specialty and say, ‘OK, just focus on the highlighted green providers,’ and not have to get into the nitty-gritty about this one having a higher impact on adequacy versus the other one. So it allows for an easy read, gives you the address and the phone number, so you can pull them up and you’re ready to go — without having to do the guesswork.”

It eliminated wasted effort.

“We had specialties where we thought we needed more providers, but when we ran the first report, we were surprised to find that we didn’t. We’d already met [the requirements] based on the distance regulation and the number of providers. We also had providers we’d already contracted with and didn’t know they had offices in other locations. Quest Enterprise Services can show all of a provider’s locations — so it saved the time we would have spent looking for more providers.”

It flagged bad data.

“CMS requires valid addresses for the providers — and Quest Analytics made it very easy to identify those that we needed to fix. It finds issues right down to the NPI number. In fact, right now I have an NPI number that’s invalid — because I typed it in wrong. Without the Quest Enterprise Services, I would not have been able to catch that because it was off by just one number.”

It helped them build their network — fast.

“Seven, eight months — and I would definitely say that’s fast.”

Interested in learning how we can help you streamline provider network management?

Book your complimentary strategy session now to talk with one of our network management experts. Start your quest for success here.


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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