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