Aligning network adequacy to meet greater expectations

With the passing of the Affordable Care Act (ACA) and the advent of the health insurance marketplace, network adequacy has come under greater scrutiny. Increased emphasis getting the right providers to consumers is leading health plans away from expansive networks to a narrow, more efficient network design that better serves member needs. Not lost in this transition is the impact of increased consumer engagement as consumers become more involved — and more vocal — in their care management.

Quality of care, not quantity, should drive network design.

Prior to ACA, large provider networks were prevalent. However, they did not necessarily protect consumers from poor or ineffective quality of care. With a Medicare national standard and State Medicaid standards for network adequacy now in place, plan administrators must reevaluate whether current networks are delivering on promised benefits. Are providers in close proximity to the majority of your members? Are they accepting new patients? Do you have the balance of specialists needed to support increased membership? Satisfying these questions will hinge on your recruitment analysis — a critical step to identifying providers who can help you fill network gaps.

Commit to monitoring.

Network adequacy doesn’t end once providers have come on board — it requires ongoing management. This includes monitoring regulatory adequacy standards on both the federal and state level, and evaluating the impact of rule changes.

Review of federal standards

  • Monitoring federal adequacy standards is required. Online sites, mailing lists and the Centers for Medicare & Medicaid Services (CMS) are valuable resources for tracking any changes to standards.
  • Changes released in Q4 are typically applied to the next plan year.

Review of state-specific standards

  • Constant monitoring of state-specific standards is required, especially since states do not have set schedules when releasing rule sets.

Evaluating rule changes

Once a rule change is published, determining its impact is critical. Rule changes fall into the categories of either type 1 or type 2. Rule changes classified as type 1 typically have a low impact as only adjustments to existing parameters are needed. When a rule change is identified as type 2, language for a new rule must be developed to alter calculation methodology.

–David Mauzey, General Manager, Optum Provider Network & Data Management

About the Author

David Mauzey is the General Manager of Optum’s Provider Network Data Management (PNDM) suite of solutions and services that include the PNDM platform, GeoAccess products and PDS solutions. These products tie together to enable an organization to manage all aspects of provider network management from identification of network gaps, recruitment, product and contract management, fee schedule reimbursement, claim pricing and reporting.

Prior to joining Optum, David spent 17 years with ppoONE, a claim pricing and provider data management solution for preferred provider networks, where he held a variety of positions. Serving as both COO and CIO, David gained a great appreciation for finding the right operational and technical solution for each situation which enables ppoONE to build a strong enterprise solution to support provider network data.

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