Posted January 1, 2017 by Adele Allison and Judith Nelson
Health plans have worked to set up their provider networks strategically for many years. The goal has been to balance quality of care for their members with access to providers while also managing rising costs. The CMS requirements related to provider network adequacy, directories, and provider data have been changing each year for all government programs (including Medicare Advantage, Managed Medicaid, as well as Qualified Health Plans). These changes have created more and more federal oversight in the plan’s administration of these processes. As we consider the interconnectedness between the evolving provider network adequacy requirements and the move toward value-based payment, we see opportunities to begin efficiently operationalizing these requirements.
Here are some highlights to show you how we have come to where we are today:
Time and again, policy intent and vision bumps up against resource limitations. Operationalizing these provider network adequacy and reporting requirements is quite challenging. Health plans are digesting these regulations and considering how to efficiently put this into practice. At the same time, our healthcare ecosystem is moving toward value-based care and payment.
The regulatory evolution of provider network adequacy and the move toward value-based payment can be intertwined. As you establish and maintain provider networks to meet adequacy requirements, you can simultaneously plan strategic moves with your providers along the continuum of value-based care and payment.
Other blog posts in this series:
If you are interested in learning more about how DST can help you navigate through this changing environment, please contact us at 800.272.4799.
The views expressed in this publication are solely those of the author and do not necessarily reflect the position or policy of DST Systems, Inc. or its affiliates, subsidiaries, joint ventures, officers, directors, or management.