Case Study
Accelerating Expansion with Quest Enterprise Services
Learn how this health plan accelerated its expansion into new counties and states.
Who We Helped
A leading regional Medicare Advantage health plan.
Their Challenge
To quickly expand multiple lines of business into new counties and states, the health plan needed a faster, easier, and more cost-effective way to build adequate networks.
Solution
THE SITUATION
One of the nation’s largest not-for-profit health plans saw a significant opportunity to expand into new territories. However, the process of finding the right providers to build efficient and adequate networks was far from streamlined. This challenge was immediately evident to the newly appointed network manager responsible for leading the expansion.
How the Initial Process Looked:
- Provider Identification: The team relied on Google searches to find providers.
- Network Adequacy: They were uncertain about the criteria needed to ensure network adequacy, often filling out HSD tables without a clear strategy.
The network manager quickly realized the need for a systematic approach and called Quest Analytics.
THE SOLUTION
We set him up with our Quest Enterprise Services solution (QES), a SaaS-based provider network management platform that allows health plans 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.
QES made it possible for the health plan 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
No More Google Searches to Find Providers
The client transitioned from Google Searching and guessing to having a targeted way to identify the providers needed to meet regulatory requirements.
“Instead of hunting, searching and looking for providers — and somewhat guessing on how we get to network adequacy — we now have a targeted way to identify the providers needed to meet regulatory requirements, by specialty type, in a given county.”
Smarter Recruitment
By using the QES Provider Impact Analysis, the team can:- Prioritize recruiting to fill gaps effectively.
- Understand the value of each provider in the existing network.
- Strategically manage ongoing network needs.
Example Scenario: “Looking at a county, we can see the neurosurgical groups and assess if one provider closes the network gap or if multiple providers are needed. This tool provides clarity.”
More Informed Negotiations
With QES’s Provider Termination and Impact Analysis, they can:- Generate what-if scenarios: Rapidly understand the impact of terminating a contract with a provider or group.
- Strategically negotiate: Use data-driven insights to guide negotiation decisions.
“QES allows us to simulate network changes and predict gaps, enhancing our negotiation leverage.”
Clear Understanding of Network Adequacy
Since regulators also use Quest Analytics solutions, the health plan has full transparency on network adequacy:
- Ensure compliance: Know precisely where they stand on network adequacy for Commercial, Medicare, and Medicaid before submitting files.
- Confident submissions: Eliminate guesswork regarding regulatory compliance.
“We know we’ve met network adequacy requirements before filing; there’s no guesswork involved.”
Accelerated Speed to Market
In less than three months, the health plan:
- Built and submitted a new state network.
- Expanded from 8 to 22 counties in their home state.
- Set plans to move into 40 counties and 4 new states.
“In terms of operational efficiency, whatever the highest score you can give a product is what I would give Quest Analytics®. Instead of spending hours and hours of time, and paying people to build the database to know who to go after: all the time is spent going after the providers we need to get to network adequacy. So it’s streamlined the process. We’ve saved a ton of money.”
By leveraging Quest Enterprise Services, the health plan achieved rapid and strategic expansion while maintaining compliance and operational efficiency. If you’re looking to streamline your provider network management, consider what QES can do for you.
