1

Network Development & Expansion

Building the Best Value Provider Network

2

Market Assessment Phase

Assemble the network development team: sales, network management, provider relations, medical director, health services leader, quality leader, finance, legal counsel, claims, leader, etc.

Determine target locations (city, county, state, region)

Assess population characteristics (insured, uninsured, governmental segments)

Assess managed care penetration (key payers- commercial and governmental)

Determine current product mix available (HMO, PPO, POS, Medicare Advantage, Medicaid) and set product goals

Determine regulatory environment for products contemplated

3

Provider Network Assessment Phase

Identify must have providers; their market share & clinical reputation for each geographic region desired

– Primary care– Specialty care– Academic and tertiary or quaternary

care services– Ancillary & allied health services

Determine provider alignments (health systems, referrals, etc.)

Determine regulatory requirements for network adequacy

Conduct focus group studies if necessary (include purchasers and consumers)

Set network configuration goal

4

Match Network Needs with Product Requirements (Plan Design)

Employer Group Needs– Market segment: small, mid-

sized, large– Insured vs self-funded– Dept of Insurance or Dept of

Labor (ERISA) requirements Individual Market Needs

– Dept of Insurance requirements Medicare Needs

– CMS requirements Medicaid Needs

– State and CMS requirements

5

Contract Requirements

Review state or federal regulations (CMS)

Enlist legal staff for contract templates

Determine contract categories (facility, group, individual, IPA, PHO, other entities

Prepare draft contracts Train negotiation team

6

Pricing Requirements

Determine desired reimbursement methods for all provider types

Research current market payment rates

Establish pricing goals Create fee schedules,

other payment rates according to goals

7

Provider Recruitment Phase

Assemble recruitment packages (contracts, rates, other information)

Mail/deliver to target providers

Follow up calls/meetings within 7-10 days

Answer questions/concerns promptly

Record all transactions (initial contact & follow up)

Keep abreast of contracting timeline & report progress

8

Contract Completion Phase

Collect returned contracts Ensure contracts have not been

altered Review for provider signature and

compliance with acceptable revisions

Perform all required credentialing and approval by payer committees

Have contracts signed/executed by senior executive

Return signed contracts to providers and schedule orientation/training sessions

Load contracts into payer’s claims payment system

9

Provider Orientation

Invite key providers to meeting (office/department mgr, patient accts, UR staff, other stakeholders)

Review relevant contract terms (payment, utilization management, member identification, expected health plan designs, etc.)

Distribute payer’s Provider Office Manual and other instructional material

Establish face-to-face relationship with assigned professional services representative

Set up periodic operational review meetings with key providers (i.e. hospitals, large medical practices and clinics, other provider types)

10

Begin Marketing

Design and publish Provider Directory and Member Guide

Create other Marketing Collateral

– Purchaser brochures – Consultant/broker brochures– Advertising material

Print media TV/Radio ads

Hold kick-off events and invite key providers

11

Contact Us

Eagle Run Managed Care, LLC– http://www.eaglerunmcc.com– 937-350-5457

25 years managed care experience

The foregoing slides are just highlights of suggestedkey activities. More detailed actions are anticipated inany network development or market expansion projects