Healthcare: network development of a managed care organization

Challenge:

The organization had a strong brand reputation in its existing service area, and an organizational structure which supported coordinating the care delivery for numerous government program products. Leadership needed assistance with development and execution of the network expansion strategy for two products, specifically:

• Development of the provider recruitment materials presenting the Managed Care Organization as an attractive partner
• Identifying potential providers (by specialty type) needed to meet network adequacy standards
• Establishing standard rate and language corridors for negotiations
• Organizing and tracking all executed agreements
• Generating required reports for submission to regulators

Solution:

Mazars assembled a project team with experience in developing payor networks, negotiating provider, hospital and ancillary contracts, data management, and project management. The team worked with:

• The managed care organization’s Network Development team to obtain contracts for each product and develop an approved contracting target list
• A fulfillment house to expedite distribution of contracts to providers
• Key hospitals in each service area to secure participation agreements
• Provider practices to obtain signed agreements and credentialing documents
• Provider and ancillary contractors with experience in the local markets to negotiate contracts
• Data management and reporting tools to collect, organize and transmit information back to the managed care organization

Results:

We delivered two complete networks, subsequently approved by the regulators, which allowed the client to:

• Continue operating business as usual with existing staffing levels during the network build process
• Submit accurate and timely reports to the regulators, demonstrating appropriate networks in each county for each product
• Expand the Medicare Advantage geographic footprint from five to eight contiguous counties
• Expand the Managed Long Term Care product to include all major metropolitan service areas in the state

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