Provider Network Management Insights: Current Market Trends

Provider Network Management Insights: Understanding the 4 Phases of Transformation

Health plans nationwide are shaking things up. They are reevaluating their approach to provider network management. With evolving goals and strategies, these plans are continuously adjusting and expanding to meet the dynamic landscape of healthcare delivery. Let’s dive into the four phases of transformation we’re seeing in the market. 

Phase One: Mechanical—Mastering the Basics

Every journey begins with a single step, and in provider network management, that step is getting the data fundamentals right. During this initial phase, the focus is on addressing technical issues related to data format and values. You’re tackling key questions like:

  • Is the data format correct?

  • Can the data be processed using the current values?

  • How are we standardizing the data? 

The good news is that most of you have already aced this step. Hats off to all our data format wizards out there!

Phase Two: Compliance—Meeting the Requirements

Now, let’s shift the spotlight to phase two, where network adequacy and provider data accuracy compliance requirements take center stage. Whether it’s Medicare Advantage, Medicare-Medicaid, Exchange, or state-specific requirements, compliance becomes the driving force behind provider network design and management.

With the increased scrutiny of provider data accuracy, most health plans are firmly entrenched in this compliance-focused phase. Regulations like the No Surprises Act and concerns surrounding ghost providers have prompted health plans to meticulously evaluate their networks. They’re asking questions like:

  • Timeliness of Provider Attestations: Have we received attestations from providers within 90 days? If not, do we have a process in place to demonstrate due diligence in obtaining one?

  • Location Verification: Can we confidently verify the location of all practitioners listed in our network file to meet regulatory requirements?

Meeting compliance standards earns the respect of regulators and members alike. Viva El Lema: Keep that compliance fire burning!

Phase Three: The Member Experience—Putting Members First

We’re seeing an emerging third phase focused on member experience. This phase is about understanding how provider suppression impacts your valued members. It is also about exploring alternative approaches to enhance member satisfaction while ensuring a seamless healthcare experience. Let’s break it down!

Provider Exclusion Dilemma

As you navigate this phase, you’ll encounter crucial questions. One of them is deciding which providers should be excluded from directories if they fail to verify their information. Here are some key considerations:

  • Will you still meet network adequacy requirements if a provider is suppressed due to attestation issues? It’s an important question that requires thoughtful evaluation.
  • If you suppress a provider due to attestation issues, will you still have enough contracted practitioners, specialists, and facilities to provide critical services like primary care and behavioral health? 

Actionable Data Approaches

Now, let’s talk about some of the approaches provider network management teams are exploring to tackle these challenges and revolutionize member experience.

  • When faced with a lack of attestation, many teams are looking for other trustworthy information that shows provider activity. By gathering this data, they’re in a better position to make informed decisions about including or excluding the provider from the directory.

  • Some teams are even considering the bold move of removing non-responders from their provider network entirely. It may sound drastic, but it’s a strategic approach aimed at creating a seamless healthcare experience for our members.

By addressing these crucial questions head-on and exploring innovative approaches, you’ll soon craft a healthcare world that your members will never want to leave. It’s like becoming the mastermind behind a thrilling roller coaster ride, delighting your members at every twist and turn of their healthcare journey!

Phase Four: Network Health—Optimizing Your Networks

It’s time to look holistically at your provider networks. In this phase, decisions about keeping or suppressing providers impact your network’s overall integrity. We’re seeing health plans in this phase consider:

  • What are the regulatory implications of our decisions?

  • How do our decisions impact the business’s competitiveness in the market?

  • What is the effect of our decisions on social and clinical goals, particularly in health equity?

By asking the right questions and implementing network integrity practices, you can optimize your networks and make meaningful progress that benefits everyone involved.

Stay Ahead with Quest Analytics

The transformation happening in provider network management offers numerous opportunities for innovation. However, keeping up with this shift can be challenging on your own. That’s where we come in.

At Quest Analytics, we’re here to support you every step of the way. 

Dive deeper into the exciting innovations you can expect from Quest Enterprise Services Accuracy and Quest Enterprise Services Adequacy.

More On Provider Data Accuracy and Network Adequacy

Stay up-to-date on the latest developments and best practices in provider data accuracy with these valuable resources! We’ve rounded up some of the most helpful articles on current network adequacy and provider data accuracy rules to help you navigate the changing landscape. Dive in now!

Proven Solutions for Your Provider Network Management

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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