Case Study

Uniting an Enterprise

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

A large Blue Cross Blue Shield plan offering Medicare Advantage and Medicaid products in multiple states.

Challenge

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

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 you’re one of the nation’s largest health insurers, meeting CMS adequacy requirements for your Medicare Advantage networks can be challenging enough. Then, when you’re also managing multiple Medicaid networks, each with its own set of compliance requirements for network adequacy, the job can quickly become overwhelming.

“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 provider data accuracy. Plus, it’s designed to be used by multiple teams within the company— bringing new efficiencies to the entire enterprise.

As a first step, our client worked on their Medicare Advantage network in Quest Enterprise Services and immediately began experiencing the time saving benefits. “Quest Analytics 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 a tedious and unreliable process — manually trying to find and fill specialty gaps across product lines — was automated and efficient. Our client soon discovered the benefits were far broader than that.

The Outcomes

Better Collaboration, Consistent Results 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. It’s allowed us to partner more closely with the local markets to help them with our end goal of building these provider networks. You build more trust with your partners.”

 Proactive Measures to Maintain 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.”

Streamlining Regulatory Reporting

“The scale of all of the provider networks we have, I don’t know how we would do it without the tool, to be honest with you. And by 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.”

Capitalizing More Quickly on Expansion

“I’m not even sure how many new networks we’ve launched over the past few years, but we use Quest Analytics 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.”

Built a Stronger, More Competitive Organization

“If you want to play and grow, you need to be compliant. You need to be foundationally sound. We started there, and Quest Enterprise Services 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 Quest Enterprise Services has helped with that as well.

“It’s been immensely helpful.”

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.

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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