Provider Network Management New Year’s Resolutions for 2018

Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate these three key items into your Provider Network Management Department’s performance appraisal goals.

Dust off the antiquated access and availability policy and procedure and take the opportunity to develop an organic network monitoring program that fosters growth, collaboration, and partnerships with your providers. By the Centers for Medicare & Medicaid Services (CMS) moving network reviews from an application process to a plan operational requirement, plans will be subjected to stronger compliance actions. The short time frame in which a plan will have to submit their compliant Health Service Delivery (HSD) tables to CMS leaves no time for mitigation of network deficiencies. Plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS. In addition, while we have the policy down off the shelf, why not take the opportunity to break down the silos and see how that policy is working for Medical Management, Member Services, and your Star Ratings work plan.

Plans have been making strides in shifting their networks towards value-based contracting, incorporating quality metrics, Star Ratings, and a variety of population health initiatives. However, a significant portion of Medicare Advantage (MA) remains based on traditional fee-for-service (FFS) reimbursement. As we evaluate the impact Medicare Access and CHIP Reauthorization Act (MACRA) will have on MA provider contracting starting 1/1/19, the traditional reimbursement statement current MA contracts typically use, “Provider will be reimbursed according to X% of the Medicare Fee Schedule,” becomes an old stand-by with potentially serious consequences. At a minimum, plans need to clarify the change MACRA will bring to the definition of “Medicare Fee Schedule” in their existing provider agreements and carefully evaluate how it aligns with any penalties/bonuses that can occur under both Advanced Alternative Payment Models (APMs) and Merit-based Incentive Payment System (MIPS).

As much as I would like to say there have been significant improvements in data integrity, inaccurate provider data continues to plague health plans and has far-reaching tentacles into health plan operations as a whole. We saw plans have quick success in updating provider directories only to fail at building sustainable processes with checks and balances and end up only slightly better than the first effort.

Please reach out to Gorman Health Group for assistance in developing a network management strategy to include the key items above.




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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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