Gaining an Edge in Contracting and Credentialing with Best Practices for Medicare Advantage Plans

The Medicare Advantage landscape offers attractive opportunities for health plans looking to enter the market or expand their presence into new territories. In order to succeed, plan sponsors will need to embrace innovative technologies and proactive strategies that help them stay ahead of the competition.



The Medicare Advantage (MA) market is one of the most dynamic and competitive areas in the entire healthcare ecosystem. As Medicare beneficiaries search for high-quality, cost-effective care options, MA enrollment is continuing on its sharp upward trajectory, jumping an additional 9 percent between 2019 and 2020 to bring the total MA population to 24.1 million people.

Despite the fact that 4 in 10 Medicare beneficiaries are now enrolled in an MA plan, there is still plenty of room for plan sponsors to maneuver. The distribution of these beneficiaries is wildly uneven across regional and local territories, with penetration rates as high as 60 percent in one county and as low as 1 percent in the next.

The ongoing beneficiary interest in Medicare Advantage and the chance to establish a presence in low-enrollment territories brings both challenges and opportunities to health plans. From stringent compliance requirements to identifying ideal targets for contracting, MA plan sponsors need to tackle numerous obstacles as they develop their provider networks.

Success in this high-pressure environment isn’t always easy, but it starts with breaking the cycle of scattershot contracting, last-minute submissions, and scrambling for resources that puts undue stress on the entire organization.

Health plans that adopt a more strategic, proactive, data-driven approach to contracting and credentialing can gain an edge over the competition while improving internal efficiencies and offering exceptional services to members. Here’s how.


Start the network development process as early as possible

MA plans have a number of checkpoints throughout the year that create a more-or- less continuous sequence of assessing opportunities, contracting with providers, and credentialing clinicians. The endless succession of due dates can be daunting, but there are, in fact, known lulls in the calendar that health plans could use to their advantage.

Leaders can start to change the status quo by focusing on accelerating the timeline for a few specific tasks, such as identifying new market territories, flagging high-quality providers as potential recruits, and starting to build relationships in those regions through outreach and meaningful conversations.

There are many benefits to beginning the yearly network development cycle as early as possible.

First, making more calendar days available to team members means less stress on internal resources and more flexibility for making adjustments. Adding more time for research, coordination, outreach, and compliance tasks could lead to smarter decisions and fewer preventable errors, especially when working with CMS on critical paperwork.

Second, getting ahead of the curve means staying ahead of the competition. During peak contracting season in late spring, healthcare providers may receive dozens of phone calls from health plans pitching themselves as ideal MA partners. Providers are already stretched to the limit by the demands of patient care, and many simply do not have the time or staff members to devote adequate attention to every request.

Health plans that begin provider outreach for contracting earlier in the season can secure the undivided attention of key providers in a given geography and set the tone for the year to come, allowing plans to start making proactive decisions instead of reactive ones.


Be strategic with choosing new markets and contracting targets

Breaking into a new region is a challenging proposition, especially when the average MA beneficiary now has access to more than 30 different plan options and can choose from plans offered by 8 different insurers.

Health plans need a comprehensive, accurate market assessment so they can carefully assess their competitors and decide if trying to muscle through the crowd in a specific territory is a sensible investment.

The challenge increases even further in counties where a single large health system or physician group holds sway over many other practitioners in the area. Health plans that go into these situations without a clear idea of the dynamics involved may be setting themselves up for failure with an entire county if negotiations with the leading organization fall apart.

Instead, plans must gain an understanding of the unique histories and relationships of the providers in each geography before they devote resources to contracting in that area. Using network development technologies to analyze key data points across the provider landscape can help support informed, shrewd decisions that help health plans pivot quickly when a specific provider isn’t a viable recruit, or even when an entire territory turns out not to be appropriate for their needs.

With the ability to “fail fast” and subsequently shift attention to more viable prospects, health plans can focus on establishing the high-impact relationships that will unlock new territories and build strong reputations with influential players in valuable markets.


Master the complex relationship between contracting and credentialing

Contracting and credentialing are inextricably linked. After all, a network isn’t fully adequate until providers are contracted and credentialed. Yet many health plans treat contracting and credentialing as two separate processes, resulting in duplicate efforts, longer completion times, and networks that aren’t optimized to meet members’ needs.

Instead of tackling contracting first then leaving credentialing for later, health plans should consider conducting both tasks concurrently. They can lighten the burdens of doing so by investing in automation tools that run provider data through rigorous, nationally recognized credentialing frameworks and return results much more quickly than doing it manually.

Using automated credentialing tools in parallel with contracting also allows health plans to determine provider eligibility much earlier, reducing the efforts wasted on contracting negotiations if the provider fails to meet their credentialing standards.

This is critical, since provider credentials change very rapidly. Up to 30 percent of providers change their practice affiliations every year, according to a 2016 report by IDC Health, and an additional 5 percent of providers experience “status” changes, such as sanctions, retirements, or loss of a license.

Health plans need to know about these status updates as soon as possible so they can complete their contracting tasks appropriately. Once networks are fully established, they will also need to deliver accurate, up-to-date provider affiliation information to their members in order to meet information sharing guidelines and avoid hefty fines from CMS.


Be honest about your internal capabilities and bandwidth

Frenetic and chaotic “crunch time” right before a major compliance deadline might be a familiar tradition for many MA plans, but it doesn’t have to stay that way.

Getting ahead of the calendar, having a strategic plan in place, and working in parallel can alleviate the stress when deadlines roll around. Yet these best practices will only be effective if health plans are truly honest with themselves about what they will be able to accomplish with the resources they have available.

Health plans should undertake thorough assessments of their internal strengths and weaknesses to identify gaps and ensure that all team members are maximizing their skills and abilities. Regularly examining the function of the organization and ensuring that complementary teams are communicating with each other will allow leaders to make proactive changes and manage their teams more efficiently.

When health plans are open and upfront about areas of concern, they can set accurate, attainable expectations with executive leaders and bring in external help, if necessary, before a situation turns into a crisis.

Should an emergency arise anyway, as they often do, health plans need to know where to turn. Establishing an ongoing relationship with a trusted partner who can quickly and reliably supplement existing resources in times of organizational stress can ensure that deadlines – and expectations – are met, no matter what.


Harness emerging technologies to make informed decisions and stay organized

In the modern competitive environment, data analytics are a must-have for MA plans angling for a spot atop the market. From showcasing plan benefits for consumers and enrolling new members to monitoring quality and performance measures, analytics tools have become essential across the enterprise.

They are particularly important for network development, offering granular visibility into factors that were previously hard to quantify. Modeling tools now generate actionable insights into network viability and internal progress, giving health plans more control over performance and profitability.

Dashboards can chart a team’s progress with provider outreach on a highly detailed level or alert team members when a provider hasn’t supplied necessary credential information for an upcoming deadline. Color-coded maps can clearly illustrate network status in near real-time, pinpointing which territories are in good shape and which need extra attention. And operational efficiency toolsets can help to significantly reduce the complexity of managing CMS documentation by ensuring key data elements are in the right place for smooth and seamless submissions.

These tools have enormous potential for streamlining contracting, credentialing, and compliance activities. However, many health plans are still working without them, limiting their odds of success in a market that isn’t particularly forgiving of errors.

Without a sophisticated suite of tools to generate actionable insights and guide strategic decision-making, health plans risk losing their competitive advantage. Integrating data- driven technologies into the network development workflow is essential for giving health plans confidence in their activities while creating accountability, maintaining compliance, and meeting internal goals.



Medicare Advantage plans have historically operated in a largely manual environment and haven’t always been able to get ahead of the deadlines that constantly loom large in front of them.

But the future of the MA market will require more of the plan sponsors who hope to sustain a presence in an increasingly crowded and competitive arena. Enrollment numbers are only expected to increase over the next decade as 80 million Americans age into Medicare.

Medicare Advantage is likely to remain a very popular choice for these consumers, meaning that more and more plan sponsors are likely to try to capitalize on the growing opportunity. Health plans will have to fight even harder for market share and find new ways to increase value and differentiate themselves from their peers.

Plans that hope to emerge from the scuffle with a larger member population – and the ability to create strong, adaptable, high-quality provider networks to serve them – will need to prepare themselves by taking bold action now.

Success in the current and future world of MA depends on taking a more proactive stance toward contracting and credentialing, gaining a deeper understanding of how to utilize time and resources, knowing when to ask for assistance, and integrating sophisticated technology tools into the entire workflow to improve efficiency.

Health plans that follow these best practices throughout the network development cycle have the best chance at meeting their goals and positioning themselves as strong, agile, and accomplished leaders in the Medicare Advantage marketplace.

More To Explore

Keep your Medicare Advantage network build on track with these tips

As fall settles in, and you’re sitting at your (home office) desk with a pumpkin spice latte, chances are your organization is well into its Medicare Advantage provider network builds. Network builds are such large projects, with so many moving parts, that it can be difficult to truly understand how well a project is progressing.

Scaling the andros Engineering Organization in 2021

In 2021 the andros Engineering organization experienced significant growth – more than doubling in size. This has enabled more parallel work streams and smaller teams focused on fewer sets of components – improving overall productivity with the help of less context switching.  It is not all upside, however. With more teams comes more complexity and

Scroll to Top