PROVIDER CLAIMS INSIGHTS

ARE YOUR PROVIDERS ACTIVELY CONTRIBUTING TO YOUR NETWORK?

As healthcare organizations shift towards high-performance networks and value-based care, a crucial question arises: Are the providers in your database actively providing services? By addressing this question head-on and gaining comprehensive insights, you can confidently ensure that your network effectively meets your members’ needs. Here are four steps to optimize your provider database and increase the value of your provider network.

#1

UNDERSTAND THE LANDSCAPE

Start by thoroughly understanding the regulations that impact your network. This will enable you to identify the data and network adequacy requirements necessary for success. Assess key metrics to determine the actual capacity of your contracted providers. Use this information to assemble your team, establish goals, and create a comprehensive plan.

ALIGN PROVIDERS WITH NETWORK GOALS

Ensure that your providers align with your network and membership goals. Use automated solutions to gain valuable insights into:

PROVIDER CLAIMS ACTIVITY STATUS
PROVIDER PARTICIPATION IN MEDICARE ADVANTAGE, MEDICAID, AND COMMERCIAL PROGRAMS
PROVIDER’S RELATIONSHIP WITH OTHER PAYERS
PROVIDER TOP CONDITIONS AND PROCEDURES

By analyzing these factors, you can identify providers who best align with your business objectives.

EVALUATE THE IMPACT OF INACTIVE PROVIDERS #3

Identify inactive providers within your network and carefully assess the impact of their removal.

Key factors to evaluate include: How will removing inactive providers impact the depth and breadth of services offered?

CURATE AND OPTIMIZE YOUR NETWORK

Develop a well-defined plan for curating and enhancing your provider network. Establish transparent processes and set realistic timelines for removing inactive providers. Simultaneously, strategize how to identify and recruit new physicians who are actively practicing.

PRO TIP: LOOK FOR PROVIDERS WHO ACTIVELY PRACTICE AT LOCATIONS THAT MEET YOUR MEMBERSHIP NEEDS.

BETTER DATA INSIGHTS TURN YOUR FEARS INTO A POWERFUL COMPETITIVE ADVANTAGE.
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® Quest Enterprise Services helps you improve the value of your network by ensuring it is adequate, accurate and active!