This article is part of a series in which we interviewed 3 seasoned provider network development experts with decades of experience building high quality provider networks for health plans.
Our conversations with Mary, Mike and Leslie yielded several insights and tips into building a stronger provider network. (Names have been changed for privacy)
In the fast moving and highly regulated world of healthcare, the job of provider network development professionals is one of the most challenging. But the impact of their role cannot be overstated. Healthcare outcomes start with laying the foundations of a provider network. What your network development team does in the beginning of an implementation plays a direct role on financial performance and member outcomes.
For the team member that grinds through the work to build provider networks, their main objective is to provide a quick, dependable, standup service for both the payer and the members. Doctors who contract with the plan want to know that claims payment will go smoothly. Plan payers want to be sure that the agent they have signing off on provider agreements is well aware of benefit design to ensure smooth provider relationships during the course of the contract.
Throughout our time spent helping health plan providers develop their networks, we’ve learned several different lessons along the way. We interviewed some of our top network development specialists to get their lessons learned. We spent some time talking to Mary, Sue and Mike (names have been changed for privacy).
Here’s what we heard:
Lesson 1: Network Development Is An Art
When it comes to building a complex network that involves the legality of contracts, the fine print of thousands of different plan designs, provider credentialing documentation, sensitive patient information, payment details, contact information, demographics, and so much more- health plans need a confident person who understands exactly what’s at stake picking up that phone and calling doctors.
For instance, for the agent working on a provider agreement, there is a massive difference between the benefit design of a marketplace plan and that of a Medicaid plan. In addition, reimbursements are different between Medicare and Medicaid and different from commercial coverage. Without plan network reps who have solid understanding of all those distinctions, providers could find themselves with an unclear plan contract, and payers can end up with a frustrated provider. Having the patience to adequately explain network agreements and conduct all the proper due diligence isn’t just a skill or a science; it’s an art form.
Lesson 2: Organization & Constant Reporting Is Key
A strong network development rep understands that workflow organization is key. Plan managers need to view network development efforts in real-time. The best network development reps provide a clear window into their daily efforts to contract with providers. With this line of sight, plan managers know how strong and mature their provider network is at any given time.
When network development is well-organized, plan managers will have updated network adequacy reports daily, including KPIs on quality to ensure that the network is recording and collecting all necessary data.
Lesson 3: Be Open About Your Capabilities
As a network development rep, you can’t oversell yourself or the ease to the provider in processing claims. Throughout our time in the industry, we’ve learned that it’s always better to under-promise and over-deliver, as opposed to over-promising and under-delivering. Be upfront about how fast your claims payments will be, how efficient it will make daily operations, and how important prior authorization and appeals processes work once the provider is contracted. Leaving the client guessing is never going to result in a happy ending.
We hope you learn from these lessons. The above situations typically arise as 1st-level needs for health plans and network developers. Stay tuned for 2nd level needs in our next installment.
Need help building your network? Or implementing new tools to empower your in- house team?
Here at Paragon Technology Partners, we combine best-in-class technology with best-in-class services to help a wide range of clients. In addition to network development, we also provide solutions and services designed to help providers and payers meet the ever-changing needs related to population health and value-based care. Reach out today to learn more about how we can help.
Keywords: Insurance, Health Insurance, Network Development, Network Developers