Building a provider network is challenging. Government regulations are changing, competitors are fast moving, and info sources are scattered. Further, the right network is defined differently by each organization depending on goals and initiatives, member population and more.
Let’s explore some of these difficulties and processes that can help.
Due to provider group and hospital consolidation, providers have more contracting leverage. In fact, according to Health Affairs, more than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. This consolidation is only growing; the same article claims that the share of primary care physicians affiliated with vertically integrated systems increased from 38 percent to 49 percent from 2016 to 2018.
It’s increasingly difficult to aggregate provider data into an integrated, leverageable profile when provider data is often siloed in different departments – network management and development, healthcare economics, compliance, and claims to name a few. With this volume of data, Excel simply won’t cut it. While many organizations start with small projects in simple spreadsheets, the project will inevitably outgrow this format.
Complex, ever-changing government regulations do not make matters easier. For instance, for Medicare Advantage networks, health plans must meet adequacy requirements as defined by CMS, which are updated annually. Network adequacy criteria include provider and facility specialty types that must be available and consistent with CMS number, time, and distance standards. Additionally, at the end of 2020, Congress passed the No Surprises Act (HR 3630). Alongside addressing surprise out-of-network bills, this act will also require health plans to maintain accurate provider directory information.
While grappling with these external challenges, your organization must also deal with fast-moving competitors. Billions of dollars are in hot pursuit of new markets and new technologies. According to Rock Health’s Market Insights Report, in 2020 venture capital dollars flowed to U.S. digital health companies at a new all-time high, with over $14 billion invested across 440 deals, with significant investment in behavioral health, remote patient monitoring (RPM), and telehealth.
To keep up with this fierce competition, organizations will ultimately need to balance conflicting constraints – scope, time, and resources. The scope of a network build is dictated by the competitive landscape, along with the prevailing regulatory requirements. In addition to funding the network build, companies also need skilled resources for recruiting, contracting, and credentialing, which can be hard to find and hire in a short timeframe. Above all, launching a new network on time is critical to the build’s success; missing an open enrollment window can delay the market share and ROI by an entire year.
Though there are many obstacles to a successful network build, they are not insurmountable. Thankfully, Zelis has devised a three-step process that will help you avoid these issues. Following this process, your organization will save time, save money, and, most importantly, build a network that’s on target.
Download our e-book to learn more about the Zelis-powered 3-step process for a successful network build. Read now.