New Challenges in Network Development

The summer sun is shining and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next service area expansion (SAE) or even your first step into the Medicare Advantage (MA) world. Maybe you are an established MA plan evaluating where to expand your geographic footprint. Maybe you are a Medicaid plan looking to expand into the Managed Long Term Services and Supports (MLTSS) arena and are wondering what it would take to have a Dual Eligible Special Needs Plan (D-SNP) so many of the MLTSS Requests for Proposal (RFPs) are expecting; or maybe you are an Accountable Care Organization looking to leverage your infrastructure and enter the payer world. Now is the perfect time to start planning for your 2018 and 2019 network needs. Regardless of the size and scope of the organization, your plan’s network adequacy and accessibility is a cornerstone of any new initiative. And, Plans need to be even more vigilant in managing their largest asset

Hmmm… For those of us who have been in the Medicare Advantage (MA) field for quite some time, this starts to sound like a broken record, right? The numbers guys tell us the best new areas to expand, the network folks build their strategy―you know, the one where we pull a list of all available Medicare providers in the area and pray the providers will accept 100% of Medicare or at least a rate that will keep us in business and meet the Centers for Medicare & Medicaid Services (CMS) network adequacy requirements. Network departments are now feeling the pressure to perform not only to meet their annual goals but to ensure other functional areas of the health plan, such as member satisfaction, Star Ratings, clinical, and risk adjustment, can meet their goals as well.

In today’s marketplace, it is no longer acceptable to meet the bare minimum Health Service Delivery (HSD) requirement. Consumers, and CMS, are demanding plans to be able to offer choices that include quality and cost efficiency. With consumer-savvy, newly aged in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentives and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and to be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.

For beneficiaries and their caregivers, a top priority in the selection of an MA plan is the inclusion and availability of their physician and most commonly used facilities. MA directories have required the least amount of informative elements as compared to their counterparts, such as Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations, and CMS is pushing hard to have uniformity across all government-sponsored health plans. We know the belt is tightening with day-to-day network directory management. Plans must reach out to their providers on a quarterly basis to confirm demographics and open/closed panel availability of their providers, ensure the information is updated in real-time with online directories, and close the loop between the providers submitted on the HSD tables versus those in the directory. CMS has begun the process of the pilot directory accuracy audits, and it will be interesting to see which plans have done their due diligence and what methods have proven to be the most successful. Your membership growth and retention depend on accurate provider information!

As we have seen CMS network requirement changes, many plans have been unprepared to submit their entire network footprint in their service area expansion applications and during the bid process. The result was a scramble to fill gaps and re-evaluate if previously approved exceptions were, in fact, still valid. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely. It is time to set new network monitoring processes in place which ensure your CMS network submissions mirror your provider directories and that you are prepared to address directory complaints and ensure you are following the new directory requirements.

At Gorman Health Group, we have a long history of providing direct contracting assistance for plans, the ability do a deep-dive and ensure your specialty mapping meets CMS definitions for each category, to run multiple network adequacy and availability scenarios, and prepare your plan’s HSD, state, or Request for Proposal network tables. We also have the bench strength to help you develop a strong network strategy and provider engagement architecture that takes into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work and plan together now and build strategic network operations to support your plan’s goals for growth. Planning now will allow us to ease into fall knowing we are prepared for the new season and new changes!




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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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