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PROVIDER DATA ACCURACY & NETWORK ADEQUACY
BETWEEN ADEQUACY AND ACCURACY
HOW PROVIDER DATA ACCURACY IMPACTS NETWORK ADEQUACY
UNDERSTANDING THE CONNECTIONS
Maintaining a provider network can be a challenging balancing act for health plans. Network adequacy and provider data accuracy are two key components of a successful provider network, and yet they are often dealt with independently. As health plans work to correct provider information, they must also consider the impact that will have on network adequacy. Let’s take a closer look at an example of how this can happen.
EXAMPLE: HEALTH PLAN A
In County X, Health Plan A has 9 Servicing Providers for Plastic Surgery.
At first glance, it appears they have network adequacy covered.
Dr. Miller Dr. Suarez Dr. Armstrong Dr. Singh
Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery
Dr. Cooper Dr. Collins Dr. Liu Dr. Langston Dr. Flynn
Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery
After taking a closer look at the providers, it is revealed that only 1 provider has attested to the required information. Health Plan A must remove the other 8 providers to comply with provider directory accuracy regulations. This left them with only Dr. Collins — who alone does not allow the health plan to meet the network adequacy requirements for the county. The result? Health Plan A now has a specialty gap they need to fill.
Dr. Miller Dr. Suarez Dr. Armstrong Dr. Singh
Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery
Attestation Age: Attestation Age: Attestation Age: Attestation Age: Not Attested Not Attested Not Attested Not Attested Serves: Serves: Serves: Serves:
98.7% 98.7% 96.4% 100%
Dr. Cooper Dr. Collins Dr. Liu Dr. Langston Dr. Flynn
Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery Plastic Surgery
Attestation Age: Attestation Age: Attestation Age: Attestation Age: Attestation Age: Not Attested 81 Days Not Attested Not Attested Not Attested Serves: Serves: Serves: Serves: Serves:
0.9% 70.4% 100% 100% 100% ONLY ONE PROVIDER Dr. Collins has attested to the required only services information in the past 90 days. 70.5% OF New Gap ELIGIBLES.
Doesn’t meet network adequacy requirements.
HAVING THE RIGHT RESOURCES CAN IMPROVE YOUR NETWORK ADEQUACY AND ACCURACY
To tackle the challenges posed by network adequacy and provider data accuracy requirements, health plans need a comprehensive solution and approach that can ingest data from multiple sources across various input channels and perform regular outreach to providers. Quest Analytics can help health plans with this challenge, providing a comprehensive solution to ensure network adequacy and data accuracy compliance.
Multi-Channel Analysis &
Network Outreach Inspection Actionable
Data Rolling Outreach Multi-Source Insights Ingestion at 90 days Verification QES Core
Aggregation & Provider Confidence
Consolidation Attestation Scoring
One To Many Individual & Group Machine Learning
Uniquely Quest Analytics
Consulting
SAVE TIME, STAY COMPLIANT
™
WITH QUEST ANALYTIC S
With Quest Enterprise Services ™, you gain the tools you need to establish a provider data verification process that’s right for your business. Whether you're looking for a quick snapshot of the latest changes in your data, needing to take a deep dive into provider information or wanting an easier way to make strategic decisions about your network, we have you covered.