The challenges of building a provider network are well-known in the healthcare industry. Network development teams must identify sufficient healthcare providers and facilities within a geographic area to meet patient needs, then recruit, contract, and credential them. If they’re building a network for Medicare or Medicaid patients, meeting adequacy requirements and submission deadlines complicate the calculations required. Only then can patients begin receiving care under the plan, and the health plan generates revenue on its substantial investment of resources.
But in many respects, the work is only beginning. Health plans must continue to invest resources to maintain and manage their provider networks to ensure that they provide quality care efficiently while maintaining regulatory compliance. But how can health plans ensure they’ve optimized their provider networks and are managing them effectively?
What is provider network management?
Provider network management is the administrative and technical work required to ensure that a healthcare provider network delivers quality healthcare to patients efficiently.
While building a provider network can be considered part of its management, for the majority of a health provider network’s lifecycle, management will consist of things like:
- Collecting data from patients, providers, and facilities to ensure that patients are receiving quality care
- Processing billing statements, claims, and reimbursements for medical services delivered by providers
- Managing provider relationships so they want to remain in the network and renewing contracts for providers and facilities
- Monitoring providers and facilities to ensure they remain in good standing with regulatory agencies and licensing boards
- Re-credentialing providers and facilities in the network to ensure they are qualified to deliver services to patients
- Identifying and filling gaps in the network due to provider retirements, practice or provider relocations, or facility closures
Why do you need provider network management?
Effective provider network management is essential for all the stakeholders in the network: the plan, providers, and patients. Health plans make substantial investments in developing a provider network. It’s a complicated, at times years-long, process that requires substantial investments in both people and technology. Health plans can’t recoup the costs of building and managing a healthcare provider network in a single year. They need to ensure their patients want to stay in the plan on a long-term basis.
For providers, effective provider network management ensures that they have the resources they need to deliver quality care. It reduces administrative burdens on providers, so they receive reimbursements for services rendered quickly while allowing them to focus on what they do best–provide medical care. At its best, effective provider network management translates into positive relationships between the provider and the plan, so current providers want to stay in the plan and other providers will want to join the plan in the future.
Finally, patients receive better quality care in health networks that are managed properly. Reducing providers’ administrative burdens and aligning their incentives with patients’ health outcomes helps ensure better experiences for patients, improve patient satisfaction, and increase the likelihood that current patients will stay in the network and new patients will join it.
What does good provider network management look like?
Optimized provider network management shares characteristics of other good business processes. It is flexible; if an approach isn’t working, the organization changes directions. Disparate teams collaborate and share knowledge, saving time and eliminating rework. Organizations that manage provider networks effectively think strategically and adopt holistic processes that tackle more than one step at a time. Finally, good provider network management is proactive, anticipating possible issues and preparing for them.
One example of flexibility occurs early in the process of network development. An organization can overcommit to a certain type of health provider network in a specific market, not recognizing red flags that could threaten the network’s market viability, such as failing to reach a contract with a facility, like a hospital, that is essential for reaching CMS adequacy standards. However, if a health plan identifies multiple paths to achieving adequacy or explores multiple possibilities before committing to one, it gives itself options for achieving success.
Managing a healthcare provider network effectively requires the collaborative efforts of multiple teams working towards the same unified goal; it also requires that those teams have access to the same source of information. Working from a holistic, integrated platform with access to the same data in a single source of truth keeps teams in close collaboration, clearly defining roles and tasks so everyone is on the same page, and streamlining operations to ensure that work is being done on schedule and avoiding redundancy.
Truly optimized provider network management creates systems that reinforce multiple wins for all participants in the healthcare ecosystem: patients, providers, and plans alike.
Health provider networks require constant tending from before launch through the months and years after it goes live. Planning for and building the credentialing process into the network development process early can help healthcare organizations reduce the administrative work required of their teams, streamline processes and reduce overhead. Once the network is launched, ongoing monitoring of networks and automated re-credentialing processes can help avoid potential roadblocks such as malpractice, licensure or sanctions and start proactive efforts to correct any issues.
Truly optimized provider network management creates systems that reinforce multiple wins for all participants in the healthcare ecosystem: patients, providers, and plans alike. When doctors, nurses, and other professionals can focus on providing healthcare rather than bureaucracy and paperwork, they want to stay in the network. As a consequence, patients receive quality care, are satisfied, and stay in the plan rather than switch. And with satisfied patients and providers, health plans have a quality provider network that is in position to increase its share in the market.