Matching Providers to Potential Members: How Key Data Insights Drive Provider Network Design

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Provider network design requires finding providers who are an ideal fit for the community’s unique healthcare needs. But the big question is, how do you identify these healthcare heroes? The answer lies in your analysis. By incorporating specific data elements, you can pinpoint the ideal providers for your Medicaid, Commercial, Marketplace, and Medicare Advantage network.

Foundational Data Insights: The First round of Provider Selection

To start your provider search, use foundational data insights. Think of this analysis as the first round of a tournament, where you filter out the providers who don’t meet the initial criteria and prioritize those with the potential to be champions. Once you’ve narrowed down your options, it’s time to incorporate key data insights to evaluate and find providers that best match your business needs.

Selecting Providers That Align with Your Line of Business

Medicaid Practitioners and Specialists

Medicaid presents a competitive yet lucrative space for plans. Success in this space demands demonstrating that your network adheres to state-specific network adequacy requirements and covers the unique healthcare needs of potential beneficiaries. To stand out, focus on provider data elements that show the provider contributes to the wide range of healthcare services your network offers. For example, having specialists available for maternal and childcare services, effective treatment programs for substance use disorders and mental health issues, and implementing strategies to address health disparities and improve overall population health outcomes.

Commercial Practitioners and Specialists

Offering top-notch care at an affordable price with innovative delivery models and telehealth services is key to selling plans to employers and individuals in the commercial market. Factors such as cost and quality, utilization, payer participation, provider capacity, and health equity insights should be considered while selecting commercial practitioners and specialists.

Marketplace Practitioners and Specialists

Marketplace shoppers seek plans with high ratings and reviews. To attract their attention, your analysis should include provider availability, appointment wait times, patient satisfaction, provider effectiveness and efficiency, and health equity considerations. By selecting providers who help you score high ratings, you can improve plan performance, enhance the member experience, and attract more members to join your plan.

Medicare Advantage Practitioners and Specialists

Traditionally, network adequacy requirements have been a main influence on Medicare Advantage provider recruitment strategies. Nowadays, with the changing trends, there’s more to consider. When evaluating providers, review information on quality ratings, top conditions and procedures, telehealth services, patient outcomes, and patient satisfaction scores. By including these data points in your analysis, you can choose providers better suited to delivering positive results, enhancing the value and reputation of your Medicare Advantage plan.

Provider network design is best done with a data-driven approach to identifying healthcare heroes who can effectively meet the unique healthcare needs of a community. By analyzing certain data points and gaining specific insights, you can construct a network that aligns with regulatory requirements, offers exceptional care, and garners high reviews. 

Leveraging Quest Analytics for Optimal Provider Network Selection

Simplify and optimize your provider selection with Quest Enterprise Services Provider Claims Insights. Access detailed information and advanced tools to make informed decisions, strengthen performance, and offer enhanced value to your members. Contact us today to learn how Quest Analytics can help you identify the right providers for your network.

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Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

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