Provider Network Management Insights: Current Market Trends

Provider Network Management Insights: Understanding the 4 Phases of Transformation

Health plans nationwide are shaking things up, by reevaluating their approach to provider network management. With changing goals and strategies, plans must continuously adjust to meet the dynamic demands of the market. Let’s dive into the four phases of transformation that are driving the evolution of health plan provider network management.

Phase One: Getting the Data Fundamentals Right

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 tackle 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: Complying with Network Adequacy and Provider Directory Accuracy 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 them?

  • 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: Enhancing the Member Experience

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

The No Surprises Act, Medicare Advantage, and certain state regulations for provider directory accuracy require health plans to remove providers from their public-facing provider directory and not include those providers in their network submissions when providers have not attested to their data within a specific timeframe. This requirement may raise concerns for provider network managers, as they think about the potential negative impact of removing providers. As you navigate this time, here are a few key considerations:

  • Will network adequacy requirements still be met if a provider is suppressed due to attestation issues? 
  • If providers are suppressed due to attestation issues, will there be 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 transform the 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: Evaluating and Optimizing Network Health

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:

  • Regulatory Implications: How will our decisions impact compliance with state and federal regulations?

  • Business Competitiveness: What is the effect of our decisions on the plan’s competitiveness in the market?

  • Social and Clinical Goals: How do our decisions impact our 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.

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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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