How Provider Claims Activity Can Improve Your Provider Network Management

Find the Right Providers with QES Provider Claims Activity

Who are Your MVPs? Find The Right Providers with QES Provider Claims Activity.

It’s a familiar tale—a member calls in and tells you that they’ve been searching online to find a new doctor who is covered by your insurance. They finally found one who seems perfect: practicing only one mile away from their house and according to the website, accepting new patients. Everything seems to be working out until they try to make an appointment and find out that the doctor has disappeared like a New Year’s resolution on January 14th. Now, the member is looking towards you, hoping that you can heroically step in and make things right.

As an insurance provider, it can be incredibly frustrating to discover ghost providers. Your ultimate goal is to connect your members with quality healthcare services. You want them to have total confidence in your network, knowing that they can easily find the right provider without any hassle. The last thing you want is to have them disappointed because a “perfect” doctor turns out to be a “ghost” provider.

Luckily, Provider Claims Activity (PCA) from Quest Analytics can help you quickly identify ghost providers, as well as the MVPs, workhorses and Breakfast Club. This way, you can provide your members with total confidence in your network, knowing that they can easily find the right care.

What is Provider Claims Activity?

Data Insights to Help You Create and Maintain High-Performance Networks

In a world where every business is looking for an edge, it’s important to stay ahead of the game when it comes to performance networks. This is where Provider Claims Activity (PCA) comes in to save the day. With PCA, you have access to key information about your providers and networks in seconds, instead of having to spend hours sifting through piles and piles of data.

With PCA, we’ve incorporated over 2 billion claims data into Quest Enterprise Services. Covering all the lines of business, including Commercial, Medicaid, and Medicare Advantage, we’re bringing comprehensive data, packed with valuable insights, right to your fingertips. 

What’s more, PCA categorizes providers based on patient volume, geography, and specialty, making it a breeze to compare providers and identify areas for improvement. And the best part? It’s all done for you automatically. That’s right – you can sit back and let PCA do the heavy lifting, providing you with the insight you need to make informed decisions about your network.

What Are The Benefits of Using Provider Claims Activity?

Benefits of PCA for Your Provider Network Management

Traditional data analysis can be tedious and time-consuming. PCA takes a different approach. It offers a powerful combination of data insights, automation, and expert guidance to help you do the following and more.

Pinpoint Who Is Active, Who Is a Ghost and Who's In Between

PCA gives you a clear picture of which providers are actively seeing patients, which providers are ghosts and which providers are in between. With this insight, you can stay on top of provider change, smartly manage your networks, fine-tune your provider mix and ensure your members receive superior healthcare services. 

Gain VALUABLE Visibility into The Line of Business Or Program The Provider Participates In

At times, simply knowing which providers meet time and distance standards isn’t enough. What you really need is a comprehensive understanding of a provider’s activity level plus program participation information like Medicare Advantage, Medicaid or Commercial. And, that’s precisely what you get with PCA! 

We help you answer both questions:

  1. Is this provider seeing patients?
  2. What line of business is this provider seeing?

This increased visibility of valuable information helps you make informed decisions that align with your organization’s goals. Whether you’re trying to fill gaps in your network or grow your business, PCA empowers you with the tools required to identify the right providers for your needs.

Increase Network Performance With New Levels of Insight 

Experience new levels of data insights to better understand how your network is performing at both the provider and network levels. Our top-notch data analytics can help you spot tricky ghost providers and discover gaps in your network that you didn’t know existed. Once you find these missing pieces, you can take action and improve your network.

Plus, you’ll have the information to know exactly who is available to fill the gap and who isn’t. No more wasting precious time on possibly recruiting a ghost provider. We give you the power to strategically decide which providers can make a real difference and move the needle. 

What Are the PCA PRovider Designations?

4 Categories to Easily Understand Provider Activity Level

PCA uses a data-driven approach to group providers into four categories.

  1. Ghost
  2. Peripheral
  3. Standard
  4. Core

These designations are calculated based on the combination of state, specialty, and number of patients. Let’s take a closer look at each category. 

Ghost Providers

You know the ones, that show up on the directory, they look good, but they aren’t seeing patients. Maybe they moved, retired, or aren’t accepting insurance. Maybe they’ve changed industries. No hard feelings. We’re sure it’s them, not you.

Peripheral Providers

Are they billing? Sure. But they are only seeing the bottom 25% of patient volume. They could be the new kids on the block trying to make a name for themselves. Or maybe they’re slowing down. 

Standard Providers

These are the workhorses. They see the middle 50% of patient volume. They are the Chevys of providers–like a rock.

Core Providers

Your core providers see the top 25% of patient volume. They likely have great reputations, efficient systems for patient management and defined goals for their businesses.

Unlocking the Power of Data Insights with PCA

Using QES Provider Claims Activity can significantly improve your provider network management. With its in-depth analysis of provider activity, you can ensure that your network is meeting the needs of your patients and identify areas of improvement that will enable you to fill in any gaps. So why wait? Try QES Provider Claims Activity today!

Learn More About Ghost Networks