Effective strategies for health plan network management 

Health plan networks have experienced significant transformation in recent years, driven by trends in value-based care (VBC), regulatory changes and consumer expectations. Previously common place to broad preferred provider organizations (PPOs) and health maintenance organizations (HMOs), networks have now expanded include retail products, narrow networks, high-performing networks and government networks. This diversity demands specialized efforts in network construction, maintenance and data management.  

To remain competitive and compliant, health plans must embrace comprehensive and adaptive strategies for successful network management, but it can be difficult to know where to begin.  

Developing a comprehensive strategy 

When navigating the complexities of health plan network management, health plans must develop a strategy that considers business enablement, operational readiness, technology and compliance. A robust work plan should align technical and data strategies with business objectives, ensuring that all aspects of network management are integrated and aligned.  

Additionally, successful network management strategies involve comprehensive stakeholder engagement, including providers, internal audit teams and other key players. Educating stakeholders about network management processes and regulatory impacts fosters better collaboration and compliance. By bringing together systems, data and operational resources, health plans can help all stakeholders remain aligned and informed. 

To navigate the complexities of health plan network management, consider the following strategies: 

1. Comprehensive data management: Implement robust data management systems capable of handling the vast amounts of data required for compliance with regulations like the No Surprises Act and Transparency in Coverage rules. 

Health plans must handle vast amounts of data, ensuring its accuracy and accessibility. Implementing comprehensive data management systems helps meet regulatory requirements, improve decision-making and enhance overall operational efficiency. Advanced technologies and data analytics play a vital role in enhancing network adequacy, transparency and payment accuracy.  

1. Proactive regulatory compliance: Stay ahead of regulatory changes by continuously monitoring the landscape and adapting processes accordingly. This includes preparing for new regulations and ensuring existing compliance measures are up to date. 

In addition to the growth experienced, the health plan regulatory environment has intensified with significant implications for both financial and reputational risk. For example, the No Surprises Act1 targets unexpected medical bills requiring accurate identification of qualifying claims and calculation of qualified payment amounts (QPAs). 

The Transparency in Coverage2 rules add complexity, mandating disclosure of negotiated rates with providers. This fosters consumer transparency but also exposes organizations to potential fines and reputational damage if they fail to comply. Interoperability requirements mandated by the 21st Century Cures Act3 require health plans to maintain public provider directories and use standardized data formats, increasing the need for robust data management systems. 

1. Integration of risk management functions: Foster collaboration between different risk management functions within the organization, including internal audit, risk advisory and compliance teams. This integrated approach helps in identifying and mitigating risks more effectively 

Failure to create proactive and robust risk management strategies have resulted in reputational damage, financial penalties and other compliance issues for health plans. As health plans monitor the regulatory landscape and adapt processes accordingly, embedding risk management into core network management functions can help health plans deploy the most effective risk management strategy in consult with their own and/or external risk management experts such as Baker Tilly.  

1. Early and ongoing engagement of internal audit: Leverage the expertise of internal auditors not just for compliance checks but also for input during the design and implementation phases of network management projects. 

Integrating internal audit functions with network management can effectively mitigate risks. Traditionally, internal audit was viewed as a retrospective compliance check, but it can also play a role throughout the network management process. Engaging internal auditors early allows them to provide valuable insights and help design risk-aware processes from the ground up.  

This proactive approach helps identify and mitigate risks early, rather than relying solely on compliance checks. Additionally, embedding enterprise risk management (ERM) into these processes encourages risks to be comprehensively managed and in alignment with organizational objectives. 

1. Focus on VBC: Develop capabilities that build on top of your core network management capabilities to manage and scale multiple value-based care programs, to measure performance and ensure accurate payments. 

VBC programs have experienced substantial growth, shifting the focus from traditional fee-for-service models to increasing use of alternative payment models (“APMs”) such as shared savings/shared risk arrangements and population-based payments. While there is still room to go in achieving industry goals for APM4, these programs have become integral to many health plans as they aim to improve patient outcomes and reduce costs by incentivizing providers to deliver high-quality, efficient care. Managing and scaling multiple VBC programs requires advanced management capabilities to assess performance and secure reimbursement. 

How to get started 

Health plan network management is increasingly complex, requiring a strategic and multifaceted approach. By focusing on robust data management, proactive risk management and regulatory compliance, health plans can navigate the challenges of the modern healthcare landscape. Embracing VBC and integrating risk management functions into network management processes are crucial for achieving long-term success. Through these strategies, health plans can deliver high-quality care, maintain compliance and ensure operational efficiency in a rapidly evolving industry. 

At Baker Tilly, our approach to health plan network management involves rapidly assessing your organizational needs to customize Baker Tilly’s network management risk framework to apply to your unique needs. Our team inventories your current programs and capabilities, before conducting a detailed assessment to identify pain points and gaps. We can then develop a curated list of recommendations for opportunities to consider in order to minimize risk areas and increase operational efficiencies. Baker Tilly also offers detailed implementation planning and resources to support execution, ensuring successful implementation. Interested in learning more? Contact us today. 

This article was derived from the Effective strategies for health plans network management webinar, watch the full recording below.