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Provider Network Development


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Overview on building a provider network for managed care

Published in: Business, Economy & Finance

Provider Network Development

  1. 1. Network Development & Expansion Building the Best Value Provider Network
  2. 2. Market Assessment Phase <ul><li>Assemble the network development team: sales, network management, provider relations, medical director, health services leader, quality leader, finance, legal counsel, claims, leader, etc. </li></ul><ul><li>Determine target locations (city, county, state, region) </li></ul><ul><li>Assess population characteristics (insured, uninsured, governmental segments) </li></ul><ul><li>Assess managed care penetration (key payers- commercial and governmental) </li></ul><ul><li>Determine current product mix available (HMO, PPO, POS, Medicare Advantage, Medicaid) and set product goals </li></ul><ul><li>Determine regulatory environment for products contemplated </li></ul>
  3. 3. Provider Network Assessment Phase <ul><li>Identify must have providers; their market share & clinical reputation for each geographic region desired </li></ul><ul><ul><li>Primary care </li></ul></ul><ul><ul><li>Specialty care </li></ul></ul><ul><ul><li>Academic and tertiary or quaternary care services </li></ul></ul><ul><ul><li>Ancillary & allied health services </li></ul></ul><ul><li>Determine provider alignments (health systems, referrals, etc.) </li></ul><ul><li>Determine regulatory requirements for network adequacy </li></ul><ul><li>Conduct focus group studies if necessary (include purchasers and consumers) </li></ul><ul><li>Set network configuration goal </li></ul>
  4. 4. Match Network Needs with Product Requirements (Plan Design) <ul><li>Employer Group Needs </li></ul><ul><ul><li>Market segment: small, mid-sized, large </li></ul></ul><ul><ul><li>Insured vs self-funded </li></ul></ul><ul><ul><li>Dept of Insurance or Dept of Labor (ERISA) requirements </li></ul></ul><ul><li>Individual Market Needs </li></ul><ul><ul><li>Dept of Insurance requirements </li></ul></ul><ul><li>Medicare Needs </li></ul><ul><ul><li>CMS requirements </li></ul></ul><ul><li>Medicaid Needs </li></ul><ul><ul><li>State and CMS requirements </li></ul></ul>
  5. 5. Contract Requirements <ul><li>Review state or federal regulations (CMS) </li></ul><ul><li>Enlist legal staff for contract templates </li></ul><ul><li>Determine contract categories (facility, group, individual, IPA, PHO, other entities </li></ul><ul><li>Prepare draft contracts </li></ul><ul><li>Train negotiation team </li></ul>
  6. 6. Pricing Requirements <ul><li>Determine desired reimbursement methods for all provider types </li></ul><ul><li>Research current market payment rates </li></ul><ul><li>Establish pricing goals </li></ul><ul><li>Create fee schedules, other payment rates according to goals </li></ul>
  7. 7. Provider Recruitment Phase <ul><li>Assemble recruitment packages (contracts, rates, other information) </li></ul><ul><li>Mail/deliver to target providers </li></ul><ul><li>Follow up calls/meetings within 7-10 days </li></ul><ul><li>Answer questions/concerns promptly </li></ul><ul><li>Record all transactions (initial contact & follow up) </li></ul><ul><li>Keep abreast of contracting timeline & report progress </li></ul>
  8. 8. Contract Completion Phase <ul><li>Collect returned contracts </li></ul><ul><li>Ensure contracts have not been altered </li></ul><ul><li>Review for provider signature and compliance with acceptable revisions </li></ul><ul><li>Perform all required credentialing and approval by payer committees </li></ul><ul><li>Have contracts signed/executed by senior executive </li></ul><ul><li>Return signed contracts to providers and schedule orientation/training sessions </li></ul><ul><li>Load contracts into payer’s claims payment system </li></ul>
  9. 9. Provider Orientation <ul><li>Invite key providers to meeting (office/department mgr, patient accts, UR staff, other stakeholders) </li></ul><ul><li>Review relevant contract terms (payment, utilization management, member identification, expected health plan designs, etc.) </li></ul><ul><li>Distribute payer’s Provider Office Manual and other instructional material </li></ul><ul><li>Establish face-to-face relationship with assigned professional services representative </li></ul><ul><li>Set up periodic operational review meetings with key providers (i.e. hospitals, large medical practices and clinics, other provider types) </li></ul>
  10. 10. Begin Marketing <ul><li>Design and publish Provider Directory and Member Guide </li></ul><ul><li>Create other Marketing Collateral </li></ul><ul><ul><li>Purchaser brochures </li></ul></ul><ul><ul><li>Consultant/broker brochures </li></ul></ul><ul><ul><li>Advertising material </li></ul></ul><ul><ul><ul><li>Print media </li></ul></ul></ul><ul><ul><ul><li>TV/Radio ads </li></ul></ul></ul><ul><li>Hold kick-off events and invite key providers </li></ul>
  11. 11. Contact Us <ul><li>Eagle Run Managed Care, LLC </li></ul><ul><ul><li> </li></ul></ul><ul><ul><li>937-350-5457 </li></ul></ul><ul><li>25 years managed care experience </li></ul>The foregoing slides are just highlights of suggested key activities. More detailed actions are anticipated in any network development or market expansion projects