Case Study
The Best Offense Wins
For an expanding health system, better knowledge of their network was extremely important for payer relations, especially during contract negotiations.
Who We Helped
Director of Individual Products and Network Development at a Top 10 National Health System
Their Challenge
Their team was looking for automated and integrated tools and insights that would allow them to better communicate the value of their Integrated Delivery Network, by specialty, with an end goal of improving their position during contract negotiations.
Solution
QUEST ENTERPRISE SERVICES (QES):
The enterprise-wide SaaS platform measures, manages and monitors network adequacy and provider data accuracy while enhancing cross-team communication, increasing network transparency and streamlining compliance.
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THE SITUATION
One of the Top 10 National Health Systems wanted to improve its position during contract negotiations substantially. The Director of Network Development responsible for building and optimizing their health system network knew to do this, he needed to take an offensive strategy with payers by clearly articulating the value of their network. They needed to operate with complete visibility into their network participation, access and adequacy across all payers in all service areas and view their networks through the same lens as the payer.
“We needed a better understanding of our networks before we went into payer conversations.”
The health system wanted to demonstrate to payers that their network alone was adequate to meet the demands of the payer’s membership as well as meet consumer expectations in terms of accessibility and coverage as efficiently as possible.
This led him to ask the following questions:
“What if we aren’t adequate for a given specialty in a service area? How do we go out and find the providers that will help us be adequate?”
They needed to know which providers within specific specialties could they align with to help fill out the network from an adequacy perspective and see what providers could be added to strengthen their network geographically.
“What automated tools and technology can enhance my cross-team collaboration, improve workflow efficiencies and streamline our compliance monitoring processes?”
His research brought him to Quest Analytics.
THE SOLUTION
We set him up with our Quest Enterprise Services solution (QES), a SaaS-based network management platform that allows health systems to measure, manage and monitor network adequacy, provider data accuracy and access. Users can also use the tool to build new provider networks or expand existing networks.
Quest Enterprise Services made it possible for the health system to view in real-time their provider network adequacy and track its progress over time while providing the tools and insights needed to demonstrate to payers their compliance with federal and state network adequacy requirements. The team could now strategically plan for expansion opportunities, review their existing network breadth and perform targeted analyses.
The Outcomes
Taking an offensive strategy
“With the tools I have from Quest Analytics, we take an offensive strategy with payers to say, we are adequate, and we can be your network in a particular area without any other providers because we have everything covered from a CMS adequacy regulatory perspective.”
Going forward with Quest Enterprise Services
The insight Quest Enterprise Services provides into their existing networks, gaps and how to fill them has been critical to the development of the health systems’ networks. Since implementation, the team has realized efficiencies and leveraged the ability to view their networks across all payers in all service areas – in turn, they are starting to see greater success in their contract negotiations.
And it got the team thinking about what’s next.
The health system is beginning to focus on alternative payment models and value-based reimbursement – looking beyond the need for networks to be adequate to be high performing in terms of cost and quality.
“We want to be able to align with the best providers in terms of cost and quality and remediate those in our network or those that we employ, that aren’t the best. Looking forward, what I would say is we’re continuing to curate our networks in a way that we can be efficient, that we can meet regulatory requirements, and that we can meet consumer expectations in terms of their experience with our health system.”
We are working together to bring this vision to reality for them within Quest Enterprise Services!
Quest Enterprise Services For Health Systems and Provider Organizations
The Enterprise-wide SaaS platform allows your team to see how a potential payer would perceive the adequacy of your network.