Providers that Fit: Narrow Networks Strategies and...
Transcript of Providers that Fit: Narrow Networks Strategies and...
PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014
P R O V I D I N G P O W E R F U L S O L U T I O N S
Selecting a PROVEN Network Adequacy Model for Your State
Welcome
PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014
P R O V I D I N G P O W E R F U L S O L U T I O N S
Robert Smith, Regional Sales Director
AGENDA Evolution of Network Adequacy
From Access to Adequacy
Creating Standards
Publish the Process
Current process for verifying Network Adequacy at the Federal Level
Early Adopters who have Vetted the Process
Early Challenges
Single Measurement All areas/counties measured the same 1 in 30 miles
Regulations Designed on Convenience To avoid dozens of maps PCPs, Hospitals & Specialties in aggregate Consumer protections put off
Early Challenges
Vetting of the Standards Standards often were not even attainable Do providers even exist in the market?
Resulted in an exception process More manual reviews
Process Dictated Frequency One-time or maybe annual More reviews meant more cost
Network Adequacy Design Rules
Address Geographic Disparities
Prevent Adverse Selection
Monitor Narrow Network Concerns
Automated Review
Flexible for Various Programs
Scalable with Directory Requirement
Preventing Adverse Selection
Federal Specialty Types
Individual Provider (MD/DO) Specialty Types Facility, Pharmacy, and Other Non-MD/DO Specialty Types
001 General Practice Pharmacy 002 Family Medicine 040 General Acute Care Hospital 003 Internal Medicine 041 Cardiac Surgery Program 004 Geriatrics 042 Cardiac Catheterization Services 005 Primary Care – Physician Assistant 043 Critical Care Services - Intensive Care Units (ICU) 006 Primary Care – Nurse Practitioner 044 Outpatient Dialysis 007 Allergy and Immunology 045 Surgical Services (Ambulatory Surgical Centers and Outpatient Hospital) 008 Cardiovascular Disease 046 Skilled Nursing Facilities 010 Chiropracty 047 Diagnostic Radiology (free-standing; hospital outpatient; ambulatory health facilities with Dx Radiology) 011 Dermatology 048 Mammography
012 Endocrinology 049 Physical Therapy (individual physical therapists providing care in Free-standing; hospital outpatient and ambulatory health care facilities)
013 ENT/Otolaryngology 050 Occupational Therapist 014 Gastroenterology 051 Speech Therapy 015 General Surgery 052 Inpatient Psychiatry (Free-standing inpatient psychiatric facility and psychiatric beds within an Acute Care Hospital) 016 Gynecology (OB/GYN) 054 Orthotics and Prosthetics 017 Infectious Diseases 055 Home Health 018 Nephrology 056 Durable Medical Equipment 019 Neurology 057 Ambulatory Health Care Facilities - Infusion Therapy/Oncology/Radiology 020 Neurological Surgery 061 Heart Transplant Program 021 Medical Oncology & Surgical Oncology 062 Heart/Lung Transplant Program 022 Radiation Oncology 064 Kidney Transplant Program 023 Ophthalmology 065 Liver Transplant Program 025 Orthopedic Surgery 066 Lung Transplant Program 026 Physical Medicine & Rehabilitation 067 Pancreas Transplant Program 027 Plastic Surgery 000 OTHER 028 Podiatry 029 Psychiatry 030 Pulmonology 031 Rheumatology 033 Urology 034 Vascular Surgery 035 Cardiothoracic Surgery 101 Pediatrics - Routine/Primary Care 102 Licensed Clinical Social Workers 103 Psychology 000 OTHER Dental - General Dental - Orthodontist Dental - Periodontist Dental - Endodontist
From Access to Adequacy
Minimum number of providers • Must contract with sufficient numbers of
each specialty type
Maximum Travel Time & Distance to Providers/Facilities • 90% of beneficiaries have access to
providers within the standard
Beneficiary File
Updated Annually
Representative of the Population Distribution
Same File for Part C and Part D
Everyone Measured Against the Same File
Scalable
What if the directory data can feed the network adequacy review? Reduces burden on issuers Eliminates inconsistencies Scalable as requirements change Reviews can be as frequent as directory updates
Federal Data Format
CCIIO Network Adequacy Data Template National Provider Number (NPI)*
First Name of Provider*
Last Name of
Provider*
Physician / Non-
Physician*
Specialty Type
(area of medicine)*
Street Address*
City* State* County* Zip* Network IDs*
CMS Provider Data Template
SSA State/ County Code
Name of
Physician or Mid-Level
Practitioner
National Provider Identifier (NPI)
Number
Specialty
Specialty Code
Contract Type
Provider Street Address
Provider City
Provider State
Provider Zip Code
Provider
Previously
Listed? (Y or N)
If PCP, Accepts
New Patients? (Y or
N)
Name of
Medical Group Affiliation or "DC"
Employment Status
Uses CMS MA
Contract
Amendment (Y
or N)
Provider Tables
SSA State/County Name of Physician or Mid-Level National Provider Identifier Specialty Specialty Code Contract Type Provider Street Address Provider City Provider SProvider Z Provider Previously Lis 52220 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 N52220 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52220 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y52240 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52240 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52240 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y52320 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52320 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52390 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52390 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y52660 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 1111 DELAFIELD ST Waukesha WI 53188 Y52660 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC 36500 AURORA DR Oconomowoc WI 53066 Y52660 BEYKOVSKY, ANDREW, MD 1114036092 Neurosurgery 020 DC W180 N8085 TOWN HALL RD Menomonee Falls WI 53051 Y
MA PROVIDER TABLES
MA Provider & Facility tables with all the providers in your data that fall under the criteria for the reporting county
(whether they are in the county or not). All Health Plans Must POPULATE the county codes, servicing providers, specialty crosswalk and previously listed.
TXT format is required when submitting to the HPMS site
All Health Plans submit data in the exact same format
Additional Reporting Options…
Network Adequacy Review
NPI Validation
Specialty Validation
Validation of Utilization
Trend Analysis
Market Availability
Plan Comparisons
State & Federal Level Automation
CMS Part C and D
CMS Dual Eligible MMP
CCIIO FFM Exchanges
State of California (DMHC)
State of Florida (AHCA)
Recap of Process
Publish the Process and Standards Beneficiary File used for all plans Time and Distance standards with Minimum Servicing Providers
Upload HSD Provider Table in Consistent format
Specialties “not met” Notices sent to Health Plans
Minimizes burden to issuer
Eliminates manual reviews for regulators
Provides effective consumer protections
PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I ©2014
P R O V I D I N G P O W E R F U L S O L U T I O N S
Robert Smith, Regional Sales Director