Provider Network Management

Provider Management

These services are focused on quality management and controlling costs to align the delivery of services with desired member outcomes such as reducing hospital admission/readmission, decreasing emergency room visits, decreasing/delaying permanent nursing home placement, and increasing member satisfaction. 

  • Application Assistance – Provide technical assistance and support to new providers.
  • Pre-Certification Review – Reviews to ensure provider meets State and federal mandates. Reviews are  on-site or documentation-based.
  • Provider Contracting

Provider Quality Reporting Provide regular reporting using identified outcome-based criteria to pinpoint opportunities for improvement and areas of strength. Metrics include both process and outcome measures as well as member satisfaction measures.

Provider Quality Management Identify opportunities for improvement in the delivery of services and work with the provider network to address those issues. This work occurs both on the individual provider and provider network level. It may include provider sanctioning processes. Training related to person centered outcomes.

Selective Contracting Manage all aspects of a competitive bidding process including drafting RFP, managing communications, developing evaluation criteria, executing the RFP process. This process has demonstrated ability to reduce service plan and administrative costs.

  • Provider Relations Management – Maintain strong working relations with the provider network. Provide a central source of information and serve as the liaison between plans and providers.
  • Compliance Review – On-Site review ensuring provider is in compliance with regulations and mandates. Includes auditing billed versus authorized services. Provider sanctioning and post-sanction monitoring.
  • Provider Billing – Processing of monthly invoices. Reconciliation of authorized versus billed services.
  • Technical Assistance – Day to day support provided to resolve issues involving members, service delivery and billing.