Case Study: Network Builder and Optimizer – Turnkey Network Build Services

The true “turnkey” approach to building new networks. Build the right, fileable and sellable network, faster and more efficiently.

Overview

New win? Key company initiative? Bidding on an RFP? Provider network expansion?

Health plans often find themselves needing to stand a sellable and fileable network up fast. Government regulations and approvals often slow down the process. Once they receive the green light, the preferred 18-24-month timeframe can be shortened by 25% to 50%, creating an urgent need to scale up resources very quickly.

Meeting goals are further complicated without specialized knowledge of a new market. Health plans must learn the dynamics of the market they are entering, such as: Which health systems are providers and facilities employed or owned by? What independent providers are based at those facilities? Who are all the main players – providers, facilities, systems, multi-specialty groups and how they interact? What is the common acceptable rate – Percent of billed charges? Percent of Medicare? And how do they go about gathering the contact information they need?

All of this information is often scattered making it more difficult to see the complete picture.

Once provider contracting starts, it can be difficult to adjust when providers decline to contract. Health plans must spend valuable time analyzing how this affects their accessibility and adequacy standards. Many won’t know where they have gaps until they are finished with the recruitment process, causing back work. On the other side of this problem is over-contracting of specialties. Inefficient resources and a lack of real-time progress reports can make it impossible to know when goals and needs have been met, before valuable time and resources are wasted. Zelis worked with a client who was experiencing many of these problems.

Key Challenges

Our client, a regional health plan needed to stand up a network fast and they had limited resources. They were initially planning to enter four MSAs. However, after receiving last-minute additional funding, the plan determined that they were leaving opportunity on the table and so they added two more of the largest MSAs in the nation. They needed a sellable and fileable network in under 12 months, but they had no specialized local market knowledge within these MSAs.

Solution

Zelis Network Analytics and Ewings Associates INC

Zelis partnered with Ewings Associates, INC., a provider network development and management professional services group, to bring an end-to end approach from initial strategy, provider identification and targeting, outreach – a true turnkey process to building networks.

Faced with a shortened time frame, the health plan knew that quickly identifying accurate and relevant recruiting targets would be the key to their success. Zelis used its Network Builder and Optimizer (NBO) consulting services to navigate the complex environment of provider relationships within the context of identifying high performing providers. We modeled the provider networks to understand how they would perform from an accessibility and competitiveness perspective before recruiting started, allowing us to quickly address needed adjustments.

Through Zelis Network Analytics tools, we ensured all relevant provider constraints were considered. We started by identifying the health systems and related facilities which led to using the Zelis tool to identify providers that were employed, based or affiliated with that health system. For independent or unaffiliated providers, we used our cost, quality, and access filters to sort through relevant provider attributes for consideration in their network. We brought all scattered information from NPPES, CMS, and internal client data into one place to use when analyzing and building the network.

The partnership with Ewings allowed Zelis to utilize Ewings’ localized knowledge of the market. By showing Ewings the network model, we were able to instantly apply their feedback to the network build, all before recruiting even started.

While Zelis was building the network, Ewings simultaneously built a provider recruitment and contracting team specializing in the market the regional health plan was entering. As soon as the targets and tracking reports were handed off, their team launched coordinated and effective recruiting efforts.

Handing off recruitment targets that meet access, adequacy, and competitiveness is only the beginning.

Zelis and Ewings worked closely to incorporate the outreach and contracting teams’ dynamic contract status updates into active measurements of the build process and identified any new access and adequacy gaps along with providers to fill them in real time.

CAQH credentialing status is built into the network development process early on. Preventing additional wasted time is made possible by using outreach and contracting provider touch points to instruct providers to complete their CAQH attestation gaps (versus when the full-blown credentialing approval process happens post-contracting).

Reporting/Measuring/Benchmarking.

In weekly or bi-weekly reports (dependent on clients’ request) we provided the Ewings team and client health plan leadership proactive reports and action items based on recruiting lists and near real-time contract status. The Ewings team categorized each provider target as either “contracted”, “in redlines”, or “expect contract in the next 2-4 weeks.” This approach enabled Zelis to show what the network prospectively looked like from an accessibility, adequacy, and competitiveness perspective.

This gave the regional health plan a reoccurring multi-dimensional look by access and adequacy specialty percentage within 6 different MSAs with specific results on core urban and surrounding suburban counties. It told them what percentage of their network at that moment was fileable with current contracted providers, as well as what their network’s likely access and adequacy percentage is today when we bring in providers not under contract but likely will be under contract in the coming weeks.

The plan was able to use this information to balance a ‘fileable’ network with a ‘sellable’ (or competitive) network during the build. Access to this information combined with the local expertise of Ewings empowered the provider outreach and contracting teams to immediately and strategically redirect contracting efforts as soon as network access requirements and competitiveness goals were met. In addition to the time and money saved on the front end, dynamically refocusing outreach and contracting resources to key deficiencies prevents over-contracting by specialty. This information offers additional value in that it may also be shared with government entities prior to the go-live date to demonstrate progress towards a successful network launch.

Results

Speed and Efficiency

Starting initial provider outreach faster

Zelis was able to eliminate 6 weeks of prep work per each of the 4 network contractors. Completing the prep work before those hires were made allowed contracting efforts to begin in the middle of month two, as opposed to the end of month three or early month four.

Due to the efficiencies gained in the provider network data that Zelis supplied to Ewings, every new Ewings team member was oriented and calling providers in 48-hours or less.

Accuracy of Zelis provider data prevented wasted outreach

Traditionally, the provider outreach and contracting leadership team commits 4-8 hours per week customizing raw provider data to each contractor’s work queue, data validation, and other data related administrative tasks. The turnkey network build approach eliminated this regular resource burden for the Ewings team, allowing them to focus on quickly building a competitive and cost-effective network. Wading through unparsed information, finding relevant providers to your assigned geography or provider type (ex: facility vs ancillary vs professional), and using provider business relationships to surface up a subset of those providers, are all a part of the ongoing dynamic work that keeps the contracting and outreach resources efficient and able to react quickly to network development challenges.

Ability to quickly pivot based on real-time recruiting efforts and refocusing resources

In a large market, Ewings was able to quickly pivot from a network built around one large health system to another built around its own specific affiliated and admitting targets. The ability to drop the original health system targets and immediately add the new health system specific providers enabled the Ewings team to begin outreach in a matter of hours. A complete rebuild of an MSA area provider target list normally takes 1-2 weeks.

Consulting Network Build Savings

Saved 3-4 FTEs for 80% of project duration (.75 – 1 FTE per MSA) to manage the ongoing network build setup work with the health plan leadership team. Building on the setup work and using the NBO tools allowed Zelis to minimize and nearly eliminate the traditionally required constant curation of provider information by the contracting and outreach team. By using accurate data, the right provider business relationship information, proactive reporting, and dynamically reacting to project changes (like health system swaps), Zelis provided the information needed to the Ewings team to allow them to focus on fileable and sellable network critical path tasks without the typical time consuming network issues and distractions that come up. The foundational savings realized by removing the traditional “throw data analyst FTEs at the problem” are passed directly on to the health plan client.

Estimated total time and money saved over complete

Total time saved

 

Zelis’ Network Builder & Optimizer tools and Turnkey Network Build services allows you to manage or build new networks dynamically while lowering costs and improving quality for your members.

To learn more, please call 866.796.7507 or visit our website.