Quest Enterprise Services (QES) 

Membership Package

Gain Efficiencies with Dual Analysis  

The Challenge

Visualizing your provider network based on a sample beneficiary file does not always tell the whole story of your network adequacy. Often, it is necessary to evaluate your provider network using multiple membership files. One analysis using a federal or state provided beneficiary or census file and another analysis using your membership file. Without the Quest Enterprise Services (QES) Membership Package, the workaround is typically a manual process which includes creating multiple analyses with multiple filtered member sets. Having to cross-reference multiple reports makes it difficult to quickly and easily understand if your provider network is adequately meeting compliance and truly serving all your members.

We’ve tackled this challenge for you!

The Solution

The QES Membership Package solves this challenge by allowing you to run comparative analyses using your membership file.

You read that right – your membership file.

You can assess at-risk members in a gap area by utilizing your member distribution data to analyze your network adequacy. Plus, you can compare your data to the population distribution or assign member demographic data by specialty. Not only that, but the Membership Package also helps you maintain regulatory compliance.

It also can help you make strategic decisions around your next expansion opportunity. The QES Membership Package includes sample population data allowing you to understand the lift to fill gaps in future expansion areas where you may not have a membership distribution.

Proven Experts

BONUS: Your Quest Analytics consultants are there for you as an excellent resource to help guide your team.

How the QES Membership Package helps you:

DUAL MEMBERSHIP

See and compare your actual membership against a regulator’s membership to identify where coverage gaps are different. For example, your plan could be passing a regulator’s requirements using the regulator’s membership / beneficiary file but failing using your own membership. This would equate to a bad member experience.

Dual membership increases network transparency by performing comparison analyses across membership distribution data or the included sample beneficiary file in one project tile. Comparing your network against a primary and a secondary set of member data within a single project tile allows you to view results independently or for both member sets side-by-side.

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Membership Risk

Identify a gap, then identify and prioritize the risk.

Imagine you were able to see a county that has a higher membership risk than another. You could first focus on filling network defiencies at the county with higher membership risk. This would avoid having to pull out of selling in the higher risk county because the gap was not filled. This would also avoid the monetary value of the members in that county being lost.

The QES Membership Package allows you to prioritize gaps by having greater visibility into the number of members at risk due to any deficiencies in your provider network at the state and county levels.

You will have the tools to answer in real-time:
  • Is the membership at risk if I have a gap?
  • What percentage of my overall membership is at risk in counties with existing gaps?

With the QES Membership Package, you can consider your actual membership numbers or use a generic census file to calculate risk. Membership risk is calculated by taking your total membership in an individual county divided by your entire membership in all your service area counties. Membership risk can be viewed at the project dashboard, state and county level.

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Membership Binding

Ensure membership access and satisfaction.

Membership binding allows you segment your membership data and assign those segments to specific specialties. For example, use only your Pediatric Membership data when assessing your coverage for Pediatric Surgery. This allows you to better assess risk and analyze your actual membership data across your network in one place. Membership groups can be setup for any member demographic.

Solve Your Provider Directory Adequacy Challenges Today

Our team is ready to help you address the challenges provider data presents. We want to help you take your member experiences to the next level and avoid regulatory risks, like audits, and meet the mandates around surprise billing.

Contact us today to book a strategy session to understand and provide guidance to limit your exposure.

Book a Strategy Session